East Kent Hospitals Annual Report and Accounts 2013-2014 by East Kent Hospitals University NHS Foundation Trust

Annual Report and Accounts 2013/14

Putting patients first

East Kent Hospitals University NHS Foundation Trust

Annual Report and Accounts 2013/14 Presented to Parliament pursuant to Schedule 7, paragraph 25[4] (a) of the National Health Service Act 2006

foreword

Nicholas Wells, Chairman From the perspective of both clinical and financial performance, 2013/14 was another successful year for East Kent Hospitals University NHS Foundation Trust (EKHUFT). However, as we predicted in our foreword to last year’s annual report, the operating environment facing the Trust did indeed turn out to be extremely challenging. Against a backdrop of new organisational arrangements for the commissioning of services from EKHUFT, continuing resource constraints and many other pressures, the Trust’s results for 2013/14 are arguably therefore all the more impressive. Yet we should be clear that the pressures will continue to intensify in future years and that sustained success will only be achieved with significant changes to the way EKHUFT organises and delivers its services. In 2013/14 EKHUFT maintained its position among the better performers as measured by the health sector regulator’s (Monitor) access governance targets – the top rating of green being achieved throughout the year with the exception of Q1 when the Trust was rated amber green. This was due to a disappointing 6

increase in the number of Clostridium Difficile infections compared to the same period in the previous year. Taking the year as a whole, the nine and four additional cases of Clostridium Difficile and MRSA respectively over 2012/13, probably reflected the greater and more difficult workload faced by the Trust during 2013/14. Despite this, EKHUFT remains among the leading Trusts in this and many other areas, including, in particular, hospital mortality, with rates that are about 20 per cent better than the national average. Turning to finance, turnover during 2013/14 reached a new high of nearly £521.5 million. This growth was fuelled by significant rises in the number of patients seen and treated by the Trust’s hospitals – both outpatient numbers and elective daycase treatments, for example, increased by about 5% more than originally forecast in the commissioning contract. The growth in activity contributed to a surplus of £5.9 million which was, however, about £2 million less than the underlying figure recorded in the previous year. In large part, this was a reflection of higher operating costs than expected and the Trust Board’s decision at the start of 2013/14 to achieve a lower surplus in anticipation of funding additional staffing to underpin its quality objectives. Capital investment remained buoyant in 2013/14, with a total of £31 million being spent on a variety of

initiatives. Significant expenditure on diagnostic technologies (endoscopy at the William Harvey Hospital and CT scanner at the Queen Elizabeth The Queen Mother Hospital), cardiac laboratory facilities and, of course, the construction work started on the new hospital in Dover, accounted for nearly half of the year’s capital spending. Many other highlights of the year are described in the following pages of this report but we would like to make particular mention of a number of these here. The Francis Report into the Mid-Staffordshire NHS Foundation Trust had been published shortly before the start of 2013/14 but recognising its enormous significance, the Trust put together a comprehensive action plan based on Francis’ findings which commenced implementation during the year. At the same time, we launched our “We care” programme to promote values and behaviours consistent with providing patients using our hospitals with excellence in care and experience. Quality, embracing safety, effectiveness and experience, is and will remain the top priority of EKHUFT. The year also saw the successful completion of the Trust’s first large scale charitable appeal which has enabled state of the art digital equipment for mammography imaging to be provided at all three of our hospitals. And staying with the ‘charitable theme’ EKHUFT forged an exciting relationship with the charity ‘Hope for Tomorrow’. This

organisation provides vehicles which enable chemotherapy treatments for cancer patients to be delivered near to their homes, thus saving them the journey onto one of our hospital sites. With more than 1.2 million patient contacts and more than 7,000 staff, it is inevitable that we have been able only to touch on a small fraction of all the Trust’s activities during 2013/14. But one thing is absolutely clear: none of EKHUFT’s achievements would be possible without the hard work and commitment of our staff and we offer them our sincere thanks for their fantastic efforts. We also want to thank many others without whose contribution the Trust would not be able to function as it does – particularly our volunteers, who now number more than 300, and our hospitals’ Leagues of Friends (and special mention should be made of the Kent and Canterbury Hospital League which celebrated its 60th anniversary this year). And finally we wish to record our gratitude to the Council of Governors for their important contribution to the governance processes of EKHUFT and for the increasing number of opportunities they have taken to meet with the Trust’s membership.

strategic planning. Much effort has already been focused on our clinical strategies and this is feeding into thinking about our five to ten year strategic direction. Change is inevitable but if it is to be successfully embraced it is essential that our staff and external stakeholders are involved in helping to determine the way forward. We will ensure that such involvement takes place as we embark on 2014/15.

Stuart Bain, Chief Executive Officer

Nicholas Wells, Chairman

Stuart Bain, Chief Executive Officer

As we indicated at the beginning of this foreword, the environment in which EKHUFT operates continues to change and become ever more challenging. The organisation’s future success will therefore depend on its ability to understand and effectively respond to such changes and this puts a premium on high quality 7

contents 1 about our year page 9

strategic report page 20 Our strategy, our objectives and how we are doing - from performance to finances

quality report page 47 Our performance on patient safety and patient experience

directorsâ&#x20AC;&#x2122; report page 138 Our directors and our staff

how the Trust is run page 145 About our Board of Directors, our Council of Governors and our governance of our Foundation Trust

We are more than 7,000 staff.

We care for a local population of around 720,500.

We are a University Trust. We play a vital role in the training of doctors, nurses and other healthcare professionals.

This year, we treated people around 1.2 million times We improved in 9 out of 10 categories in the national inpatient experience survey

We recruited more nursing staff after reviewing ward staffing levels We ended the financial year in a good financial

position, with a ÂŁ5.9m surplus

We had 11,174 public members at the end of

March 2014 and 7,013 staff members We are a Foundation Trust, which means local people, patients and staff can have a greater say in our decisions.

Many members took part in roadshows and surveys to tell us how we are doing - including stroke care, dementia care and nutrition

care 9

about our year Our new values In January 2014, we formally adopted our new values, which are:

“Every member of staff she has encountered has made her feel welcome and at ease. We have certainly experienced the impact of East Kent's 'We care' commitment.” Relative’s comment on patient opinion website

People feel cared for, safe and confident we are making a difference

We have now changed the way we recruit and appraise our staff to make sure we are all working to these values. We are also working to make sure our values are reflected in our environment and in the way we provide information to patients and visitors. Staff throughout our hospitals are also signing up to be ‘We care champions’ helping colleagues know and understand our values and listening to patients’ experiences of our hospitals and their suggestions for improvement.

People feel safe, reassured and involved

Ward staffing review We have recruited more nursing staff after reviewing ward staffing levels this year. The review was based on the judgements of the ward managers, who met individually with the Chief Nurse, Assistant Director of Nursing and matrons, taking into account the new Royal College of Nursing guidelines for adult nursing ratios. The key points of the review were: • Although most ward managers felt that in normal circumstances the number of staff they are allocated is correct, extra beds when the hospitals are busy and maternity leave are both not currently properly accounted for, which leads to staffing difficulties • In some specialist areas, staffing allocations have not kept up with how ill today’s patients are, and the extra numbers of patients • In some surgical and specialist areas, the current skill mix is not appropriate out of hours for the illness severity of patients. As a result, we developed business cases for extra nursing staff in medicine, older people, stroke and paediatrics. Our nursing leads are also looking at increasing the time ward managers have for clinical leadership and supervising the quality of care, in line with the Francis recommendations (see below), and removing administrative tasks to support this. We will continue to review nursing staffing regularly.

Responding to the Francis report Around 300 staff took part in our staff listening meetings to discuss how we should respond to the issues raised in the Francis report. In the meetings we specifically asked staff to discuss what they thought were the key issues for the Trust to address. Some of the practical issues raised at the meetings were able to be addressed quickly, including tackling issues around accessing replacement equipment and reviewing ward staffing to take into account increasing activity and complexity of patient care needs. Some of the long-term issues, for example, deep-rooted cultural issues identified by staff, such as barriers between professional groups, are being taken forward as part of ‘We care’. We also invited frontline staff to take part in the Board of Directors’ discussions about the key themes of the Francis report. 11

about our year Heart first at William Harvey Hospital, Ashford In February the William Harvey Hospital became one of the first hospitals in the country - and the first in Kent - to implant the smallest heart monitoring device available. The wireless miniature device is one-third the size of a AAA battery and nearly invisible to the naked eye for most patients. It allows physicians to continuously and wirelessly monitor a patient’s heart rhythm for up to three years.

“The procedure went very well and recovery was almost immediate.”

The device is used for heart patients who experience symptoms such as dizziness, palpitations or unexplained, recurring fainting who cannot be diagnosed through the usual tests. Dr Mehran Asgari, who carried out the first implant, said: “The procedure went very well and the recovery was almost immediate for the patient.”

Hope for Tomorrow Hope for Tomorrow, a national cancer charity, gave us a Mobile Chemotherapy Unit in October. This helps reduce the distances patients have to travel to receive their cancer treatment. On board the fully-equipped mobile unit, people can receive chemotherapy treatment in Hythe, Herne Bay, Whitstable and Dover rather than travelling to the acute hospitals in Canterbury, Ashford or Margate.

Improved day hospitals We are offering more and more hospital treatment in daytime clinics that do not require an overnight hospital stay. We refurbished our day hospital at Kent & Canterbury and William Harvey hospitals to provide additional clinic rooms, up-to-date facilities and a better environment for patients.

People feel confident we are making a difference

Top 40 hospital We were ranked as one of the UKâ&#x20AC;&#x2122;s top 40 hospitals for the fifth year in a row. Health intelligence specialists CHKS presented us with this award after evaluating 22 indicators of safety, clinical effectiveness, health outcomes, efficiency, patient experience and quality of care.

Older person team wins national award Our care of the older person teams at William Harvey Hospital and Ashford Clinical Commissioning Group scooped the HSJ Efficiency in Community Service Redesign Award this year for a project to give care home patients an alternative to hospital. A team of community matrons, GPs and a consultant geriatrician assess new patients at care homes. They work with the patient and their family to develop a care plan should the patient become very unwell and provide clinical support for complex cases both within the care homes and for GP patients. This has led to a significant reduction in inappropriate admissions to hospital from care homes.

Inpatient Survey: we improved in 9 out of 10 categories We improved in nine of the ten categories of questions in the 2012 national inpatient survey. The biggest improvement â&#x20AC;&#x201C; an impressive 25% increase in patient satisfaction â&#x20AC;&#x201C; is in the area of waiting lists and planned admissions. There have also been some clear improvements in standards of communication and privacy. A&E and the Emergency Departments have seen a 10 percentage point improvement and discharge has seen a 5 percentage point improvement. You can find more information Where we fell down was a low number of respondents about our quality confirming that they had received information about how to improvements in complain about the care they had received. We have since our Quality Report reviewed the information we provide to patients. on page 47

about our year

Developing our services New Dover Hospital We are investing £23m to rebuild the hospital at Dover to provide modern facilities for the south Kent coast population. In summer 2013, we secured formal planning permission for the new Dover Hospital. This hospital is now well on the way to being built and is due to be completed by the end of Spring 2015.

Scan to see more! If you have a smartphone or tablet you can scan this code to see a film about the new Dover hospital.

In April 2013 we opened an interim trauma unit at William Harvey Hospital, Ashford.

Parking improvements In October 2013, we introduced a new ‘pay on foot’ public parking system at WHH, K&C and QEQM. Pay on foot means that people only pay when they leave the car park, not as they arrive. This brought a number of benefits to people visiting the hospital including: • visitors only pay for the time they actually use • patients running late for their appointments no longer need to find change and pay for parking on arrival • patients or visitors who stay longer than they expected no longer need to think about when their ticket runs out.

We are moving to electronic (as opposed to paper) health records. Our Electronic Patient Record (ePR) database now contains over four million patient documents.

People feel confident we are making a difference

Improved facilities for heart services In 2013 we finished building an extra cardiac catheter laboratory (an operating room with X-ray where we treat some heart problems) at William Harvey Hospital. We also refurbished the existing laboratory, adding the latest equipment. Having two laboratories helps us provide Kent’s only pPCI service - a procedure for patients who have had a particular type of heart attack.

Keeping the lights switched on In February 2014, we completed work to replace the generators at QEQM

An extra CT scanner for QEQM In December we opened our £500,000 extra CT scanner at QEQM, doubling the number of people able to receive tests quickly at the hospital. The latest scanning technology means scans are far faster and the pictures it gives us are of much higher quality. This means we can see more of what’s going on inside the body. We have begun telemedicine in some areas. For example, if necessary a patient with a diabetic foot condition can be seen immediately We continue to develop by a vascular surgeon our electronic system for in another hospital monitoring our inpatients’ using the telemedicine health. It means doctors equipment. can see patients’ test results immediately, at any time through mobile devices. We began using it for monitoring infections and saw an immediate decrease in infection rates.

VitalPAC

about our year

On the road... Every year we offer our members a variety of health roadshows, where they can meet health experts, ask questions and tell us how we can improve our services. This year, we held roadshows on dementia, stroke and nutrition.

Dementia roadshows Over 200 people attended membership events in Canterbury, Dover and Margate about dementia in May. Joy Marshall, a team of specialist dementia nurses and Dr Philip Brighton all gave presentations and manned very informative stands at all the events. Members were extremely pleased to hear about the improvements we have made in the care of dementia patients and participated in lively discussions. The feedback we received was invaluable in improving services for the people of east Kent. Photo: The nutrition stand at the dementia membership events.

Stroke In November, nearly 200 members enjoyed presentations from a variety of our stroke professionals including Louise Ward, Sandra Sidders, Andrea Reid, Dr David Hargroves, Dr Hardeep Baht, Dr Olivera Martinovic, our stroke coordinator Alison Arthurs and Dr George Thomas. External organisations such as Carers Support, Homeâ&#x20AC;&#x201C;instead, Stroke Association and East Kent Strokes were also on hand to give advice to our members.

Feeding back Over 150 of our Foundation Trust members and Governors attended Nutrition membership events in February and March, and gave feedback to help the nutrition teams further develop their services. The nutrition teams also received huge amounts of praise for the work already done to improve the quality of patientsâ&#x20AC;&#x2122; food.

People feel safe, reassured and involved

Our members

18,187 people are members of our Trust. We welcome anyone over the age of 16 who lives in England and Wales as a member and regularly attend events to recruit members. We have seven â&#x20AC;&#x2DC;constituenciesâ&#x20AC;&#x2122; of membership, with public Governors elected for each constituency. The diagram below shows membership in our public constituencies.

Where our members are Thanet 2093 members

Swale 600 members Rest of England and Wales 1896 members

Canterbury 3190 members

Ashford 1094 members

Dover 1354 members

Shepway 947 members

You can find more information about our membership on page 164 and more about our Council of Governors on page 156

about our year

Recognising staff achievements In October we held a ‘We care’ staff awards ceremony to recognise and reward the many staff nominated for innovating, caring and promoting safety during the year. Twenty two individuals and teams took away awards. Photo top: Dr Carlo Nunes won the Outstanding Innovation Award for introducing a new, better way of diagnosing small bowel problems. Photo bottom: Surgical Care Practitioner Lisa Debono won the ‘Making A Difference’ Award.

Diversity Champion Public Sector Award 2014 “The team really do care about the patients.” Comment on Patient Opinion website

In November we were pleased to win Diversity Champion Award status for 2014. The Diversity Champion Award is the International Diversity Mark which recognises and promotes organisational excellence and achievement in Diversity. The Awards highlight those organisations who actively promote diversity in ways that benefit all employees; the organisation’s clients, users or customers and the wider community.

People feel cared for as individuals

Beyond critical care Discharged patients recovering from critical illness are being looked after by a new partnership between intensive care and physiotherapy staff. People who have been critically ill in intensive care can experience many different effects after discharge – from physical issues like profound muscle wasting and fatigue to memory loss, anxiety and depression. The critical care follow-up team monitors and assesses the patient on the ward after leaving intensive care and after discharge home. They invite patients who have gone home to a rehabilitation class run on Tuesday mornings in the physiotherapy gym, where patients have the opportunity to exercise and interact with other people with similar experiences and staff who have insight into what they have been through. The team has won the ‘Best Concurrent Paper Award’ at the National British Association of Critical Care Nurses Conference 2013 and has presented its work locally at the Kent and Medway Critical Care Network.

Our charity We are grateful to everyone who has supported our Charity this year East Kent Hospitals Charity received £294,205 in donations and legacies, which go to improving the experience of our patients. Amongst many projects funded by grants from the Charity this year was the Kent Haemophilia Centre patient garden. You can find out more about the activities of our Charity on page 150

strategic report We serve a local population of around 720,500 and our vision is to be known as one of the top ten hospitals Trusts in England and the Kent hospital of choice for patients and those close to them. Our Trust was formed in 1999 when three hospital Trusts covering the Thanet, Canterbury, Ashford, Swale, Shepway and Dover areas merged to form East Kent Hospitals NHS Trust. There followed a major reconfiguration of hospital services, which saw the William Harvey Hospital in Ashford and Queen Elizabeth The Queen Mother Hospital in Margate operating as east Kent’s district general hospitals, while Kent & Canterbury Hospital in Canterbury focused on becoming a specialist services hub, alongside providing adult medical care. The Buckland Hospital, Dover, and Royal Victoria Hospital, Folkestone, provide a variety of outpatient and minor injury services. We also provide outpatient clinics in a number of locations in east Kent. This year, we consulted on improving where and how we provide outpatient services - more information about this consultation is provided on page 33.

In 2007 we became a University hospital - which means we play a vital role in the education and training of doctors, nurses and other healthcare professionals, working closely with local universities and Kings College London. We became a Foundation Trust on 1 March 2009 - which means local people, patients and staff can have a real say in the Trust’s decisions by becoming members of the Foundation Trust. Members elect the Trust’s Council of Governors, which represents the local population. NHS Foundation Trusts remain fully part of the NHS. An independent regulator called Monitor, which is directly accountable to Parliament, oversees the Trust to ensure it is acting properly as an NHS Foundation Trust.

Our staff At the end of 2013/14, we employed 7,403 people, who all contribute to our aim of making sure every patient feels cared for, safe and confident that we are making a difference. The table below shows the composition of our workforce:

Gender

Executive Director

Non Exec Director

Non Board Members

Grand Total

Female

5827

5830

Male

1563

1573

Grand Total

7390

7403

Our clinical strategy We began a review of our Clinical Strategy, driven by our clinicians, in October 2010. We are committed to: • working together and putting patients first • implementing service changes leading to improvement in quality of care • ensuring local access to emergency care • delivering sustainable services able to be developed for the future • ensuring any service changes are clinically led. So far, we have identified a number of proposals to improve outpatient services in east Kent. We consulted the public on these proposals this year - please see page 33 for more information. We are now looking at the different ways we could provide high-risk general (abdominal) emergency and elective surgery for adults and how in the interim we can carry on safely providing this service from two hospitals - currently the QEQM, Margate and the WHH, Ashford. This may mean the interim centralisation of a small number of very high-risk and acutely unwell surgical patients onto one hospital site in east Kent, rather than the current two. A number of options are being evaluated to assess which is the best and most sustainable solution for these very ill patients. We are committed to ensuring our hospital sites in Ashford, Margate, Canterbury, Dover and Folkestone, continue to provide as many services as possible for their local population. The key challenges for us in delivering our strategy include: • Ageing estate and backlog maintenance, whilst also needing to fund new buildings (for more information on our finances, please see our finance pages from page 34) • Recruitment and retention of staff in specialist areas • Public concern about changing the location or nature of health services.

strategic report How we care People feel cared for, safe and confident we are making a difference

Over the last 18 months, 1,500 of our staff and patients have been describing the values they think we should work to. In January 2014, the Trust’s Board of Directors formally adopted these as the Trust’s new values. The values are: We care so that: • People feel cared for as individuals • People feel safe, reassured and involved • People feel confident we are making a difference.

Where we care We provide services at five hospitals: • Buckland Hospital, Dover • Kent & Canterbury Hospital, Canterbury • Queen Elizabeth The Queen Mother Hospital, Margate • Royal Victoria Hospital, Folkestone • William Harvey Hospital, Ashford. We also provide services, such as dermatology (skin) clinics from other NHS facilities across east Kent. We have kidney dialysis units in Medway and Maidstone, and our specialist heart attack service based at William Harvey Hospital, Ashford, covers all of Kent and Medway.

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Other Community Sites

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Buckland Hospital

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Royal Victoria Hospital

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Queen Elizabeth The Queen Mother Hospital

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William Harvey Hospital

Accident and emergency 24-hour emergency care centre Minor injuries unit Critical Care Intensive Therapy Unit (ITU) / High Dependency Unit (HDU) Inpatient emergency trauma services Inpatient emergency general surgery Inpatient breast surgery Inpatient dermatology Inpatient respiratory Inpatient ENT (ear, nose and throat), ophthalmology and oral surgery Inpatient maxillofacial Inpatient gastroenterology services Inpatient diabetes service Inpatient rheumatology Inpatient neurology Inpatient neurorehabilitation Neurophysiology services Inpatient urology services Inpatient vascular services Interventional radiology Inpatient renal services Renal dialysis 1 Inpatient orthopaedic services Inpatient acute coronary care services Inpatient cardiology Diagnostic and interventional cardiac services Inpatient clinical haematology Haemophilia services Acute stroke Acute elderly care services Ortho-geriatric services Orthopaedic rehabilitation Therapy services Inpatient rehabilitation Cancer care (radiotherapy) Cancer care (chemotherapy) Endoscopy services Day case surgery Inpatient child health services Special care baby unit Neo-natal intensive care unit Child ambulatory services Community child health services Inpatient obstetrics, gynaecology and consultant-led maternity Midwifery-led Birthing units Outpatient and diagnostic services

Kent & Canterbury Hospital

Where our services are

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1 Also provided by EKHUFT at Maidstone and Tunbridge Wells NHS Trust and Medway Maritime Foundation NHS Trust

strategic report

Our strategic objectives 1

Deliver excellence in the quality of care and experience of every person, every time they access our services

Ensure comprehensive communication and engagement with our workforce, patients, carers, members, GPs and the public in the planning and delivery of healthcare

Place the Trust at the leading edge of healthcare in the UK, shaping its future and reputation by promoting a culture of innovation, undertaking novel improvement projects, and rapidly implementing best practice from across the world

Identify and exploit opportunities to optimise and, where appropriate, extend the scope and range of service provision

Continue to upgrade and develop the Trustâ&#x20AC;&#x2122;s infrastructure in support of a sustainable future for the Trust

Deliver efficiency in service provision that generates funding to sustain future investment in the Trust

Our annual objectives What we have achieved

1 2

Implement the delivery plan in response to Francis Inquiry Recommendations

Achieved.

Implement the second year of the Trust's Quality Strategy demonstrating improvements in Patient Safety, Clinical Outcomes and Patient Experience/ Person Centred Care

Partially achieved.

We developed and continue to implement the recommendations from the Francis Inquiry. The plan is monitored through the governance structure by the Corporate Performance Management Team on a monthly basis and by the Board of Directors bi-annually.

Good progress has been made in most areas of the Quality Strategy. We are recruiting We Care champions and planning the organisational development piece via the business case development. We have significantly improved our complaints process, with over 88% of complaints and concerns answered within one month to the satisfaction of the complainant by the end of the year, meeting the agreed target of 85%. We introduced the Friends and Family Test (FFT) to all A&E, inpatient and maternity areas and we have achieved a 15% Trust wide response rate consistently since November 2013. Wards and the A&E departments respond to the FFT feedback and examine their scores and develop action plans for improvements. Following a successful pilot of the Health & Social Care Village in 2012/13, 60 step down beds have been commissioned across east Kent. Almost 200 patients have benefitted from this model of care to date, with 73% of patients being discharged to their own homes with little or no on-going care needs. Patient and family feedback is extremely positive and only one complaint has been received in the past year. Provision of these beds has supported patient flow and achieved a slight reduction in reportable Delayed Transfers of Care, in comparison with the same period last year, however changes to working practices of external partners such as Social Services and Continuing Health Care, has limited the progress of timely patient flow across the whole system. We continue to work with the CCGs and other external partners regarding Ambulatory Care, with a further six new pathways being agreed for 2013/14. However, CCGs are keen to explore the potential for developing a process model as opposed to a pathway model, moving forward. Whilst the planned reduction of acute beds has not been realised, efficiencies have been made and associated learning has been reflected in both the Quality Improvement and Innovation hub ‘ways of working’ and the Transformation Redesign Service Improvement Programme 2014 - 2016. There have been eight Trust assigned MRSA bacteraemia cases, of which two were categorised as ‘contaminants’. Of the remaining six cases, two were deemed avoidable and four deemed as unavoidable. This is against a zero tolerance. Four of the strains of MRSA were associated with the Lyon strain. We are measured on the number of C. difficile cases that have occurred 72 25

strategic report

Our annual objectives What we have achieved hours after admission to hospital, during 2013/14 there were 49 cases. The Department of Health set us a target of 29 or fewer cases for 2013/14; this was a very challenging target and we struggled to meet trajectory in quarter 1 but returned to baseline for quarters 2 & 3. Quarter 4 was also slightly over the baseline.

Deliver the CQUIN Programmes Commissioned by CCGs demonstrating improvement and financial benefit

Achieved. The four national CQUINs (FFT, NHS Safety Thermometer, Dementia and VTE) have either already met, or are on track to achieve, targets set. Within the five local CQUINs, the maternity related measures, and the post operative complications audit of hip and knee replacement surgery have achieved the targets set. Significant improvements have been made in the Heart Failure Enhancing Quality pathway and all Enhancing Quality/Enhancing Recovery Programme measures are on track to achieve or exceed targets set with the exception of Community Acquired Pneumonia. This has been an under performing pathway but may still achieve year end target – the information for this pathway is not yet available due to data collection being two months retrospective. Currently, it is anticipated that full payment for eight out of nine CQUIN measures will be possible. We did not achieve the Stroke pathway target set.

Plan and implement Patient Administration System (PAS) upgrade to enable more efficient and productive approach to managing 18 week pathways for elective care from referral to treatment and follow-up

Partially achieved.

Reduce the number of unplanned readmissions within 30 days of discharge following an elective or non-elective episode of care, where there is a direct link to the index admission

Not achieved.

The PAS upgrade is now formally part of the Patient Administration Review Programme. A full project plan is in place and progress is being made in line with this. The go live is currently listed for January 2015. However, this is dependent upon the completion of the Patient Administration review itself, the results of which will dictate staff groups to be trained. Although the PAS was not upgraded by March 2014, improved patient tracking is now possible due to the introduction of the Incomplete Pathways Patient Targeted List.

Whilst the internal stretch target was not met by the year end good progress was made in-year and this particular objective will be maintained for 2014/15. Service Improvement to reduce unplanned Readmissions within 30 days of discharge has included four pilot interventions at K&C - the use of a 'Tick It Home' to enhance patient involvement and communication with regards discharge planning, patient/carer education, medicines reconciliation for patients identified as 'high risk' of readmissions through the Trust’s Risk Stratification tool, and the use of follow-up phone calls to high risk patients post-discharge. A more focused approach was adopted at WHH for elderly patients within a Care Home setting, through the Health Foundation’s 'Safer Clinical Systems' Project. This Project enabled an integrated approach between the Trust, Kent Community Health NHS Trust and Ashford CCG. Adjacent Initiatives such as Hospital at Home and the Health & Social Care Village model, have also assisted with the reduction of readmissions for specific patient groups.

Our annual objectives What we have achieved

Emergency Planning & Business Continuity achieving upper Quartile Performance against mandatory DH, EP & BC Indicators by March 2014

Achieved.

Engage with the new local Healthwatch and wellbeing boards while further developing relationships with vulnerable patient groups and local voluntary and community organisations through a structured programme of meetings, events and other communication channels. The overall aim is to develop and strengthen relationship and understanding between the Trust and these key stakeholders

Achieved.

Implementation of the research and innovation (R&I) strategy to increase "home-grown" R&I whilst continuing to support others’ R&I endeavours, by putting in place the right people, processes and facilities to support these goals, and through effective engagement with R&I stakeholders

Partially achieved.

Kent and Medway Commissioning Support Unit was commissioned by the CCGs to conduct an external assessment of the Trust Emergency Planning and Business Continuity Programme. This assessment was done against NHS England’s Emergency Preparedness, Resilience and Response (EPRR) Framework. The assessment identified as the Trust being 97.6% compliant. 100% compliance will be achieved with the agreement and implementation of a Business Continuity Policy, which is scheduled to be approved at the Next Emergency Planning and Business Continuity Committee Meeting (April 2014).

Two major engagement events for voluntary and community organisations were successfully delivered. In addition we held 13 engagement events for the public. The Patient and Public Advisory forum met on three occasions and has now ceased meeting. We held meetings with Healthwatch Kent, who will visit the Board of Directors meeting on 25/4/14 for discussion and signing of a Memorandum of Understanding. EKHUFT continues to meet with voluntary and community organisations and is developing meaningful relationships with organisations representing protected characteristic groups.

This year has seen a 25% increase (based on projected year-end recruitment of 1510) in recruitment to NIHR CRN Portfolio studies compared to 2012/13. In addition, there has been a 13% increase in new non-commercial CRN Portfolio studies being approved and a 10% increase in publications by EKHUFT employees. We have seen a very significant increase in research-related income, our new patient-facing website is active, important policies and processes have been put in place and patient and public involvement in R&D activities has been enhanced. We look forward to a major Trust-wide awareness raising campaign relating to research early in 2014/15. Areas where we have not achieved as expected are: increase in new ‘research groups’, increase in industry studies opening (it should be noted 2012/13 was an unusually prodigious year in this respect), move of R&D department from Dover to Canterbury (where the majority of research active clinicians in EKHUFT are based) and new patentable innovations. In many respects non-achievement of these sub-objectives relates to reasons beyond R&D’s direct control. Efforts to achieve these sub-objectives in 27

strategic report

Our annual objectives What we have achieved 2014/15 will continue and discussions with estates have already occurred recently to clarify space needs and timescales for the move of the R&D department.

Implement the marketing strategy to meet repatriation and market share targets for inpatient and day case procedures

Partially achieved. The Marketing Strategy work has led to the creation of project groups to oversee the detailed requirements for the target areas. This includes the sourcing of internal and external benchmarking data, and liaising with clinical leads for service development. The Annual GP Survey was well responded to and the findings have been analysed. The other elements of the relationship management strategy has seen an increase in contact with the CCGs.

Support increased efficiency and effectiveness across the Trust via the implementation of major infrastructure projects

Achieved. The 2013/14 Monitor plan of ÂŁ30.7m will be largely achieved at ÂŁ30.4m. Significant progress has been made on modelling the Trust's future accommodation need, including work on a long term 5-10 year strategy. 2013/14 saw the conclusion and implementation of the staff and public car parking review, with significant changes to both. The SACP (Southern Acute Cluster Programme) project is continuing to progress with three suppliers now taking part in the tendering process. The selection of the final supplier is on course to be made around June with reference visits planned and a large team taking part in the assessment process.

Drive increased efficiency and effectiveness of Trust corporate led services and activities

Achieved. The procurement service has had a fundamental review resulting in a move towards Category Management. Further work is being developed to produce a service that could be adopted by other Trusts with the combined savings and efficiency opportunities that this would present. Work has been done to improve the delivery of the in-year savings with better working relationships with the Divisions and finance colleagues.

Our annual objectives What we have achieved

Agree with Commissioners and consult with the public to implement a sustainable clinical strategy which will in particular meet the standards for emergency surgery; look to provide a trauma unit; ensure the availability of an appropriately skilled workforce; provide safe sustainable services with consideration of access for patients and their families and visitors

Partially achieved.

Develop and deploy analytical approaches to support strategic and evidence based decision making and provide clinicians with real time business intelligence

Achieved.

Ensure strong financial governance, agree contracts with commissioners that deliver sufficient activity and finance and support a comprehensive internal cost improvement programme where all Divisions deliver cash releasing savings schemes to deliver Trust QIPP targets

Partially achieved.

Interim Trauma Unit status at the WHH has been successfully delivered and a public consultation on the proposed changes for the delivery of outpatient services has been completed. The results are now being collated and validated before presentation to the Trust Board. Clarity around the future delivery of the emergency surgery pathway has also been achieved.

Increased automation of regular reporting functions has enabled staff to focus on development and enhancement of reporting, incorporating greater use of forecasting tools. Report guidelines have been published to support the education of key staff in the interpretation of information and support decision making.

Despite the shortfall in savings the Trust has managed to deliver a Monitor Continuity of Services Rating of 4 which is the highest possible rating and achieve a green Governance rating. The Trust created a robust and prudent plan. New commissioners have proved challenging to work with but we have minimised financial risk by negotiating a settlement on the highest over performing contract. Despite the contract and savings challenges and the operational activity pressures faced, we have been able to deliver a position within ÂŁ1.7m of our plan.

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Our performance How many people we treated Point of Delivery

2013/14

2012/13

Variance

Var (%)

Primary Care Referrals

137,383

128,002

9,381

7.3%

Non Primary Care Referrals

115,968

106,482

9,486

8.9%

Referrals - Total

253,351

234,484

18,867

8.0%

Outpatients - New

194,688

188,793

5,895

3.1%

Outpatients - Follow Up

417,933

389,185

28,748

7.4%

Outpatients - Total

612,621

577,978

34,643

6.0%

Elective Admissions Day Case

79,134

68,407

10,727

15.7%

Elective Admissions Inpatient

16,842

16,901

-59

-0.3%

Non-Elective Admissions

77,673

79,104

-1,431

-1.8%

Inpatient - Total

173,649

164,412

9,237

5.6%

A&E

199,982

200,085

-103

-0.1%

Elective day case admissions grew by 15% during 2013/14. Within this, services such as Ophthalmology showed significant increases due to new pathways commissioned by primary care. Elective inpatient admissions remained in line with previous years activity. This increase in day case treatments demonstrates the Trustâ&#x20AC;&#x2122;s continuing commitment to improve patient experience by reducing the number of nights that patients need to spend in hospital. Emergency Services A&E attendances remained in line with previous yearâ&#x20AC;&#x2122;s performance, emergency admissions reduced by 1.8% below the previous year with some previous emergency activity redirected through Ambulatory Care pathways. Referrals Referrals into the Trust from Primary Care saw a 7.3% increase against 2012/13. This follows a rise of 3.2% between 2011/12 and 2012/13. Outpatient attendances saw a corresponding increase of 6% against the previous year, mainly due to increasing demand in all services, especially in the Urgent Care Division.

Regulatory ratings NHS Foundation Trusts are required to report quarterly to Monitor, the independent organisation that oversees Foundation Trusts. The in-year submissions cover performance in the most recent quarter and year to date against the annual plan. Monitor evaluates the in-year returns to verify that the NHS Foundation Trust is continuing to comply 30

with its terms of authorisation. Monitor provides risk ratings for finance and governance on a quarterly basis. The following tables describe the risk ratings for the Trust during the last year and previous year (2012/13): 2013/14 Performance Annual Plan 2013/14

Quarter 1 2013/14

Quarter 2 2013/14

Green

Amber-Green

Green

Quarter 3 2013/14

Quarter 4 2013/14

Green

Under the Compliance Framework Financial risk rating Governance risk rating

Under the Risk Assessment Framework Continuity of Service rating Governance risk rating 2012/13 Performance

Financial risk rating Governance risk rating

Annual Plan 2012/13

Quarter 1 2012/13

Quarter 2 2012/13

Quarter 3 2012/13

Quarter 4 2012/13

Green

Amber-Green

In October 2013/14 Monitor replaced the Compliance Framework with the Risk Assessment Framework (RAF), From this date our financial performance has been assessed against the Continuity of Services Risk Rating (COSRR) rather than the Finance Risk Rating (FRR). Assessment of governance issues under the RAF uses a combination of existing and new methods focussing on performance against national standards, CQC information, clinical quality metrics and information to assess membership engagement. Performance will be rated as either green, no grounds for concern, or red, where enforcement action has begun. Where action is being considered but not yet taken there will be a written description outlining the concerns. A number of risks materialised through 2013/14 causing the governance risk rating to fluctuate through the year. In particular infection prevention targets were very challenging due to previous excellent performance, a risk which was declared to Monitor in the annual plan submission. Following a difficult first quarter the Trust has successfully maintained its level of performance through the year however, as predicted, was unable to remain within the stringent target of 29 cases. Other key performance issues affecting the Trustâ&#x20AC;&#x2122;s governance rating during 2013/14 related to the A&E 4 hour wait target and national cancer standards. Continued pressure on the Trustâ&#x20AC;&#x2122;s A&E departments throughout 2013/14 resulted in several months of noncompliance with the four hour standard. Increases in patients presenting by ambulance, increased acuity of patients and delays to discharging patients are all contributing factors which led to the Trust failing the standard in quarter three of 2013/14. Collaborative working with local health economy partners and continued hard work and commitment by Trust staff has enabled us to improve the flow of patients and return to a compliant position in quarter four. There were two key areas of difficulty with regards to cancer performance in 2013/14; Two week wait symptomatic breast standard and the 62 day screening standard. Significant increases in referrals via the two week wait pathway led to a shortage in capacity during quarter two, this caused the Trust to be non compliant with the two week wait standard in this quarter. Joint works with commissioners and detailed capacity and demand reviews have supported a return to compliance in this standard for the remainder of the year. The Trust declared non compliance with the 62 day screening standard in quarters three and four of this year. For East Kent this standard relates to small numbers of patients and analysis of breaches shows varied reasons for individual breaches. Themes around delays to diagnostics and capacity shortages have been addressed and compliance was achieved in this standard for March 2014 and is predicted to continue to be compliant moving forward. Monitorâ&#x20AC;&#x2122;s risk assessment framework sets out the process of escalation for Trusts. In line with this escalation process the Trust is reporting on all of the above issues on a quarterly basis to Monitor to give assurance that the Trust 31 action plans will continue to deliver sufficient and time agreed improvements and adhere to relevant targets.

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Working in partnership We work in partnership with other health and social care organisations in the region, including the local Clinical Commissioning Groups, South East Coast Ambulance Service NHS Foundation Trust, Kent Community Health NHS Trust and Kent and Medway NHS Social Care Partnership Trust. We work with Stagecoach bus company to improve public transport links to our hospitals. We also work with Canterbury City Council to provide a ‘park and ride’ bus serving Kent & Canterbury Hospital. We also have academic partners to further training and medical research and development. We have a strong programme of engagement with our members and public groups.

We have nearly 100 voluntary and community organisations (VCOs) to give us feedback on our services, plans and projects. Patients and VCO network members come together twice a year to talk about issues important to them and give their views on our services.

The breast cancer service at William Harvey Hospital has launched its service pledge, working in partnership with the charity Breakthrough Breast Cancer. Breakthrough Breast Cancer supports individual hospitals to develop their very own service pledges tailored to the needs of their local patients. Following a survey of patients who have used the hospital’s service, we launched our pledge in March, in line with what patients have told us.

Our policies in relation to social, community and human rights issues • Patient Information And Consent To Examination Or Treatment Policy • Safeguarding Vulnerable Adults Policy Including Mental Capacity Act And Deprivation Of Liberty Forced Marriage, Prevent, Domestic Abuse • Do Not Attempt CardioPulmonary Resuscitation (DNACPR) • Diversity And Equality Policy.

Our impact on the environment By 2023 an increase of 12.4% in the total population of the four Clinical Commissioning Group areas served by the Trust is predicted. This increase in activity will increase the Trusts energy requirements and associated emission of CO2e. Against this background the Trust have a legal obligation to meet emission reduction targets detailed in the Climate Change Act of 2008. Our work to cut energy costs and carbon emissions was recognised by an award from the Carbon Trust in 2014. We have completed some projects to meet our emission and energy reduction targets and support the development of sustainable operations. These include introducing a desktop videoconferencing system that reduces the need for staff travel between sites. Other projects are well advanced, such as the new hospital in Dover, which is being built to high environmental standards. When fully implemented the project plan will reduce emissions below the 2015 NHS target and deliver significant cost savings.

People feel safe, reassured and involved

Consultation on outpatient services Our doctors and nurses led work to identify a number of proposals which we believe would improve outpatient services (where patients attend a hospital or clinic or go home the same day) in east Kent. In December 2013, we began a formal public consultation in partnership with Canterbury and Coastal Clinical Commissioning Group (CCG) on the future of outpatient services. Before the launch of the public consultation we heard views and suggestions from staff and other groups and organisations by presenting at over 130 events, which included meeting with Thanet, Ashford and South Kent Coast CCGs. We currently offer more than 700,000 outpatient appointments to east Kent residents each year - around 240,000 new appointments and 460,000 follow-up appointments – which may include a consultation with a healthcare professional, tests and images (such as x-ray or scans), a treatment plan, and/or an important procedure. The consultation, which ended on 9 March 2014, proposes: • Making a wider range of outpatient services available on six sites in east Kent, so that more people will be able to have appointments within a 20 minute drive of home • Improving the outpatient departments at the Trust’s hospital sites to cater better for one-stop services in modern, pleasant environments • Providing consultation, tests, images, treatment plans and other checks all on the same day • Extending the hours that outpatient clinics are run to enable patients to attend an appointment earlier and later in the day and on Saturday mornings • Making improvements in the booking system making it more efficient and reducing the number of cancelled clinics and patients not turning up for appointments • Saving patients going to a hospital site by using technology and developing a one-stop clinic approach. We held 12 public meetings over the 13 week consultation period so that anyone who wanted to could attend and discuss their views first hand with staff and clinicians. We also offered to meet with other local groups to listen to their views. We attended a number of public and patient involvement groups and held focus groups to gather the views of individuals or communities who were unlikely to contribute to the consultation through the usual routes. The meetings were held across all the main towns in east Kent at a variety of times of the day to enable different groups to attend. All the feedback received during the consultation will be collated and independently analysed by the University of Kent, this analysis will be presented to the Trust’s Board of Directors in June 2014.

Looking after your data During the year we have had no serious personal data related incidents. Although there were no incidents meeting the criteria for serious incidents, there were two, one of which is included in the figures below, in which attempts were made to criminally deceive our staff to obtain information. One was successful. We have asked the Information Commissioner to investigate both the incidents to try to identify the offenders. This table shows the year’s data related incidents: Category Breach Type

Total

A B C D E F G H I J K

0 4 0 0 0 0 0 0 2 4 0

Corruption or inability to recover electronic data Disclosed in Error Lost in Transit Lost or stolen hardware Lost or stolen paperwork Non-secure Disposal – hardware Non-secure Disposal – paperwork Uploaded to website in error Technical security failing (including hacking) Unauthorised access/disclosure Other

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Financial performance Some headlines Our income went up by 4% this year to

£521.5m

We spent 4% (£19.2m) more than we did last year

We saved

£26.2m

Our surplus for the year was £5.9m

We spent £31m on new facilities and equipment... ...and we plan to spend £30.2m in 2014/15

About these pages This section of the annual report provides a narrative on the financial performance of the Trust, highlights points of interest within the Annual Accounts and shows the Trust’s performance against its financial targets. The Trust (excluding subsidiaries) achieved an EBITDA (Earnings Before Interest, Tax, Depreciation and Amortisation) of £29.0m which was slightly behind plan. However, the Trust achieved an actual surplus for the year of £5.9m. The financial results and the assets and liabilities of the Trust’s wholly owned subsidiary company Healthex Limited (the parent company of East Kent Medical Services Limited which manages and operates the Spencer Wing private facilities at QEQMH and WHH) have been consolidated with those of the Trust in the financial statements. This year the Trust has also consolidated East Kent Hospitals Charity. As a corporate Trustee of the Charity we have assessed our relationship to the Charity and determined it to be a subsidiary. From 2013/14 the Annual Reporting Manual for Foundation Trust’s requires subsidiary charities to be consolidated. This has been applied as a change in accounting policy with 2012/13 figures restated. The Group results, including Healthex Limited and East Kent Hospitals Charity are shown in the summary financial statements on pages 40 to 44. The Trust submits an Annual Plan to Monitor (Sector Regulator for Foundation Trusts) each financial year. The table below shows performance against this plan. In October 2013 Monitor replaced the Compliance Framework with the Risk Assessment Framework, and from this date our financial performance has been assessed against the Continuity of Services Risk Rating (COSRR) rather than the Finance Risk Rating (FRR). The performance table below shows performance against both the FRR and the COSRR. Monitor requires that NHS Charities are excluded when assessing financial performance.

Trust Performance (including Healthex Limited, excluding East Kent Hospitals Charity) Annual Plan Target Operating income Income & expenditure surplus Efficiency savings Closing cash balance Trust Capital programme EBITDA EBITDA % achieved EBITDA margin % Surplus margin % Return on assets Liquidity ratio (days) Rounded FRR (highest rating 5) Liquidity Ratio (days) Debt service cover (x) Rounded COSRR (highest rating 4)

Actual Performance 2013/14

Risk Rating

Achievement

Risk Rating

£500.6m £5.4m £30.0m £48.1m £30.8m £31.5m

£524.8m £6.3m £26.2m £44.1m £30.5m £29.7m

100% 6.2% 1.2% 1.9% 40 days 3

5 3 3 3 4 3

94% 5.6% 0.9% 1.4% 11 days* 3

4 3 2 3 2 3

12 days* 3.7 x 4

4 4 4

11 days 3.5 x 4

4 4 4

* N.B. The calculation for liquidity differs from the prior FRR measure under the COSRR with the Working Capital Facility excluded. The actual liquidity ratio was lower than planned under the FRR due to the decision taken in year to no longer hold a Working Capital Facility as the Trust has no need to draw upon such a facility and its maintenance meant the Trust incurred additional costs. The table shows a strong result for the Trust when placed within the context of the financial challenges faced by the local health economy and reflects the hard work of all our staff in providing excellent patient care whilst at the same time managing the Trust’s financial performance.

strategic report

Financial analysis – Trust (excluding subsidiaries) Income Total Trust income (£521.5m) was 4% higher than the previous year including a £15.9m (3%) increase in clinical income. The NHS Act 2006 requires that income for providing patient care services must be greater than income for providing any other goods/services, the Trust confirms that 92% of total Trust income comes from providing patient care services. Any surplus made on the remaining 8% of income is used to support the provision of patient care. The majority of income for patient care came from NHS commissioners, mainly the East Kent Clinical Commissioning Groups (CCG’s) and the Specialist Commissioning Group in 2013/14. The East Kent CCGs and Specialist Commissioning Group accounted for £443.5m of the Trust’s income in year. Tariff prices paid by commissioners were 1.5% lower due to the national efficiency target. However, the Trust was busier than expected in 2013/14 with a 7.3% year on year increase in referrals from GPs. 2013/14 Trust income - total £521.5m

n Elective £97.8m n Non-Elective £131.0m n Outpatients £76.6m n A&E £19.9m n Other NHS clinical £149.8m n Non-NHS clinical and NHS Injury Scheme £2.6m n Education & Training £13.1m n Non-patient care services to other bodies £12.3m n Other income £18.3m

We can confirm that we have complied with the cost allocation and charging guidance issued by HM Treasury.

Operating expenses Total Trust costs increased by 4% (£19.2m) compared to the previous year. The chart shows what the money has been spent on. Clinical Supplies and Medicines together account for 57% of non-pay costs. Each year we have to become more efficient - providing the same service at a lower cost or a higher quantity or quality of service at the same cost. In 2013/14 we achieved £26.2m in cost efficiencies and income opportunities, enabling the Trust to continue to meet demand and enhance services, whilst maintaining a solid financial base. 36

‘Other’ income includes: £7.4m staff recharges to other organisations £2.7m from car parking £2.0m for staff accommodation £1.6m for reversals of impairments on property, plant and equipment. £1.8m for research £1.2m charitable donations

2013/14 operating expenses - total £507.5m 2013/14 operating expenses - total £507.5m

10% 13% 1%

5% 3% 3%

59% Employee costs £301.7m Purchase of healthcare £6.5m Other clinical supplies £68.1m Medicines £48.5m 59% of total Trust expenditure is for employees’ salaries (including directors General supplies & services costs) and payment of temporary staff. Nationally, NHS£25.0m salaries rose by 1% in Premises £25.2m 2013/14. Details of directors’ salariesand andestablishment pensions cancosts be found on page 153 Depreciation and impairments £16.6m of this report. Clinical negligence premium £9.8m and other £6.1m

n Staff costs £301.7m n Purchase of healthcare £6.5m n Other clinical supplies £68.1m n Medicines £48.5m n General supplies & services £25.0m n Premises and establishment costs £25.2m n Depreciation and impairments £16.6m n Clinical negligence premium £9.8m and other £6.1m

Total pay costs increased by 3% (£9.6m) with a similar number of staff in post across most categories but with a higher number of Bank and Agency staff. Average number of staff (total 2013/14: 7,057)

The numbers shown above are average full time equivalent values. Policies for staff pensions and other retirement benefits are shown in note 5.8 of the Annual Accounts. There were 16 early retirements on ill-health grounds in 2013/14; the estimated cost (£1.4m) is borne by the NHS Pension Scheme.

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Capital expenditure We have continued our investment programme - improving and replacing property, facilities, fixed and moveable equipment, investing in technology to improve efficiency and enhance patient care and treatment. Currently we are investing heavily building a new hospital in Dover. This year we have spent £23.7m on construction projects, £4.3m on plant and equipment, and £2.5m on IT equipment and software. The main schemes and other categories of spend are shown in the following chart: Capital expenditure 2013/14 - total £31m

n WHH Endoscopy £5.3m n WHH Cardiac Lab £1m n WHH Theatre £0.3m n QEQM CT scanner £1.5m n Staff car parking £4.6m n Buckland reprovision £7.2m n Energy scheme £1.8m n Patient car parking £0.3m n Backlog maintenance/other build £2.1m n IT £2.5m n Medical equipment £3.8m n Medical equipment - donated £0.5m

In addition to the £30.5m Trust capital programme, £0.5m was spent on assets funded from donations (see page 150 for the Charitable Funds Committee Chair’s summary). A £30.2m capital investment programme has been agreed for 2014/15. We comply with HM Treasury requirements for cost allocation and charging methods, and continue to use the ‘modern equivalent asset’ basis for valuing land and buildings. Due to the rising property values the Trust’s land and buildings were indexed in 2013/14, in addition, new buildings and significant alterations to existing facilities were revalued by our independent valuer at 31st March 2014, these revaluations increased the values by £14.9m. The total value of property, plant and equipment at the year-end was £291.1m.

Cash Trust cash balances decreased by £15.9m in the year, to £44.0m. The reduction is driven by our investments in renewing our estate and equipment in order to improve our services to patients and an increase in NHS receivables, particularly in relation to Specialised Commissioners. We have accounts with the Government Banking Service, and a high street bank. Cash not required for day to day business has been invested in the Treasury’s National Loans Fund. The main categories of receipts and payments are shown in the following chart. 38

Trust cash receipts and payments 2013/14

Financial Risk Management

In accordance with the Better

Due to the relationship the Trust has with commissioners and the Payment Practice Code, we aim way those commissioners are financed, the Trust has traditionally to pay undisputed ‘trade’ invoices not been exposed to the same degree of financial risk faced by within 30 days of receipt of goods business entities. However the re-organisation of commissioning or a valid invoice, unless other to create smaller semi-autonomous commissioners has altered agreed payment terms are in force. the working relationships increasing income risks to the Trust in Under £500 interest was paid to 2013/14 compared to prior years. This is reflected in the fact that suppliers in 2013/14 under the Late final settlement of the East Kent CCG’s 2013/14 contracts has not Payment of Commercial Debts been agreed at the time of writing. As the majority of the Trust's (Interest) Act 1998. operating costs are incurred under contract with commissioners, which are financed from resources voted annually by Parliament the Trust is not exposed to significant liquidity risks. As most of the Trust’s transactions are in the UK and sterling based we have low exposure to currency rate fluctuations. Limited amounts of cash were held within commercial bank accounts during the year, reducing our exposure to interest rate risk. In addition as the majority of the Trust's income comes from contracts with other public sector bodies, the Trust has relatively low exposure to credit risk.

Paying Suppliers

Better Payment Practice Code - Measure of Compliance Category: Non-NHS

2013/14 Number

Invoices paid in the year Invoices paid on time Paid on time - % of total

£000

85,832 82,051 96%

Category: NHS

216,651 204,391 94%

Number

3,569 3,328 93%

£000

76,184 71,775 94%

2013/14 Number

Invoices paid in the year Invoices paid on time Paid on time - % of total

2012/13 178,089 168,496 95%

2012/13 £000 24,044 22,538 94%

Payment performance in 2013/14 remained close to the 95% benchmark.

Number 3,650 3,450 95%

£000 40,788 38,470 94% 39

strategic report

Ethics, fraud, bribery and corruption The Board of Directors maintains and promotes ethical business conduct, as described in the ‘Nolan’ principles (selflessness, integrity, objectivity, accountability, openness, honesty and leadership) and set out in the NHS Codes of Conduct for Board members, managers and staff, and documented governance arrangements. The Anti-Fraud, Bribery and Corruption Policy is available to all staff on Sharepoint, this is reinforced with face to face training and a dedicated page on the Trust website. Preventative work and rigorous investigation of any suspicions is carried out by the Local Counter Fraud Specialist or is referred to NHS Protect. Disciplinary and/or legal action is taken where appropriate with recovery of proven losses wherever possible.

Summarised Annual Accounts The Trust’s Annual Accounts are prepared under a Direction issued by Monitor, under the National Health Service Act 2006. The financial statements comply with Monitor’s Annual Reporting Manual for Foundation Trusts, as agreed with HM Treasury. Where relevant to NHS FTs, the Manual follows International Financial Reporting Standards as adopted by the European Union. Under the Code of Governance, the Board of Directors is responsible for presenting a balanced view of the Trust’s financial position and future prospects. The Directors consider that the Annual Report and Accounts, taken as a whole, is fair, balanced and understandable and provides the information necessary for stakeholders to assess the Trust’s performance, business model and strategy. The Directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future, for this reason the Trust continues to adopt the ‘going concern’ basis in preparing the accounts. This assumption is supported by the strong cash position and healthy balance sheet which the Trust holds at the end of 2013/14. The annual accounts have been audited by KPMG. The Directors confirm that: • As far as they are aware there is no relevant audit information of which KPMG are unaware. • They have taken all steps they ought to have taken as directors to make themselves aware of any relevant audit information and to establish that KPMG are aware of this information. The Trust can confirm there have been no regulatory investigations undertaken at the Trust this year. The following financial tables are a summarised version of the Annual Accounts. A full set of accounts (including accounting policies) can be found on our website at www.ekhuft.nhs.uk. A copy may also be obtained through our Freedom of Information Office (email: ekh-tr.FOI@nhs.net) or phone 01227 766877 ext 73636. Hard copies are available and a fee of £20 is made to non-members. The figures for 2012/13 have been restated due to the requirement to consolidate East Kent Hospitals Charity which has been applied as a change in accounting policy.

Statement of Comprehensive Income Operating Income from continuing operations Operating expenses of continuing operations Operating Surplus Finance costs Finance income Finance costs Finance expense - unwinding of discounts on provisions Public Dividend Capital dividends payable Net Finance Costs Movement in fair value of investment property Corporation Tax expense Surplus from continuing operations Surplus/(deficit) of discontinued operations and the gain/(loss) on disposal of discontinued operations Surplus for the year Other comprehensive income (movement in reserves) Impairments Revaluations Fair value gains on available-forsale financial investments Total comprehensive income/ (expense) for the year

Group 2013/14

Trust 2013/14

Group 2012/13 Restated

Trust 2012/13 Restated

£000

525,845

521,480

501,374

500,120

(511,903)

(507,503)

(489,805)

(488,274)

13,942

13,977

11,569

11,846

307 (4)

258 0

538 (2)

425 0

(72)

(78)

(8,291)

(8,164)

(8,060)

(8,105)

(7,706)

(7,817)

94 (40)

0 0

62 0

0 0

5,936

5,872

3,925

4,029

5,936

5,872

3,925

4,029

8,220 5,377

8,220 5,138

(4,222) (2)

310

19,613

19,230

(195)

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Statement of Financial Position

Group

Trust

Group

Trust

Group

Trust

2013/14

2012/13 Restated

1 April 2012 Restated

1 April 2012

£000

Non-current assets Intangible assets Property, plant and equipment Investment property Other investments Trade and other receivables Total non-current assets Current assets Inventories Trade and other receivables Non current assets held for sale and assets in disposal groups Cash and cash equivalents

2,031 294,115 787 2,923 2,357

2,031 291,147 0 48 3,884

2,164 264,588 693 2,940 4,585

2,164 261,717 0 48 6,198

1,921 265,267 631 2,644 6,041

1,921 265,267 0 0 6,031

302,213

297,110

274,970

270,127

276,504

273,219

7,695 39,285

7,695 40,580

7,191 14,816

7,191 15,862

8,081 13,718

8,081 13,802

Total current assets

0 44,704

0 43,980

0 61,028

0 59,914

0 55,623

0 54,483

91,864

92,255

83,035

82,967

77,422

76,366

Total assets

393,897

389,365

358,005

353,094

353,926

349,585

Current liabilities Trade and other payables Borrowings Provisions Other current liabilities

(59,941) (30) (2,886) (5,182)

(60,396) 0 (2,886) (5,182)

(47,557) (30) (2,863) (1,719)

(47,298) 0 (2,846) (1,719)

(44,512) 0 (1,739) (2,084)

(44,504) 0 (1,739) (2,084)

Total current liabilities

(68,039)

(68,464)

(52,169)

(51,863)

(48,335)

(48,327)

Total assets less current liabilities

325,858

320,901

305,836

301,231

305,591

301,258

Non-current liabilities Trade and other payables Borrowings Provisions

0 (35) (2,463)

0 0 (2,463)

0 (66) (2,211)

0 0 (2,211)

0 0 (2,043)

Total non-current liabilities

(2,498)

(2,463)

(2,277)

(2,211)

(2,043)

Total assets employed

323,360

318,438

303,559

299,020

303,548

299,215

Financed by (taxpayers' equity) Public dividend capital Revaluation reserve Income and expenditure reserve Charitable fund reserves Total Taxpayers' Equity

189,713 77,306 52,027 4,314

189,713 77,067 51,658 0

189,525 63,923 45,558 4,553

189,525 63,923 45,572 0

189,525 68,539 41,151 4,333

189,525 68,539 41,151 0

323,360

318,438

303,559

299,020

303,548

299,215

Stuart Bain, Chief Executive 22 May 2014

Statement of Changes in Taxpayers' Equity Group 2013/14

Taxpayers equity at 1 April 2013 Surplus/(deficit) for the year Impairments Revaluations Fair value gains/(losses) on available for sale financial investments Asset disposals Public Dividend Capital received Other reserve movements - charitable funds consolidation adjustment Taxpayers equity at 31 March 2014

Public dividend capital (PDC)

Revaluation reserve

Income and Expenditure Reserve

£000 189,525 0 0 0 0

£000 63,923 0 8,220 5,377 0

£000 45,558 5,467 0 0 0

£000 4,553 469 0 0 80

£000 303,559 5,936 8,220 5,377 80

0 188 0

(214) 0 0

214 0 788

0 0 (788)

0 188 0

189,713

77,306

52,027

4,314

323,360

NHS Charitable Funds Reserves

Total

Trust 2013/14 Public dividend capital (PDC)

Taxpayers equity at 1 April 2013 Surplus/(deficit) for the year Impairments Revaluations Asset disposals Public Dividend Capital received Taxpayers equity at 31 March 2014

Revaluation reserve

Income and Expenditure Reserve

Total

£000 189,525 0 0 0 0 188

£000 63,923 0 8,220 5,138 (214) 0

£000 45,572 5,872 0 0 214 0

£000 299,020 5,872 8,220 5,138 0 188

189,713

77,067

51,658

318,438

Group - 2012/13 – Restated Public dividend capital (PDC)

Revaluation reserve

Income and Expenditure Reserve

£000 189,525 0

£000 68,539 0

£000 41,151 0

Taxpayers equity at 1 April 2012 – Restated Surplus/(deficit) for the year Impairments Revaluations Fair value gains/(losses) on available for sale financial investments Asset disposals Other reserve movements - charitable funds consolidation adjustment

189,525

68,539

0 0 0 0

Taxpayers equity at 31 March 2013

Taxpayers equity at 1 April 2012 Prior period adjustment

NHS Charitable Funds Reserves £000

Total

0 4,333

£000 299,215 4,333

41,151

4,333

303,548

0 (4,222) (2) 0

3,365 0 0 0

560 0 0 310

3,925 (4,222) (2) 310

0 0

(392) 0

392 650

0 (650)

0 0

189,525

63,923

45,558

4,553

303,559 43

Trust - 2012/13 Public dividend capital (PDC)

Taxpayers equity at 1 April 2012 Surplus/(deficit) for the year Impairments Revaluations Asset disposals

Revaluation reserve

Income and Expenditure Reserve

Total

£000 189,525 0 0 0 0

£000 68,539 0 (4,222) (2) (392)

£000 41,151 4,029 0 0 392

£000 299,215 4,029 (4,222) (2) 0

189,525

63,923

45,572

299,020

Taxpayers equity at 31 March 2013 Statement of Cash Flows

Group

Trust

2013/14

£000

Group

£000

Trust

2012/13

Restated

£000

Cash flows from operating activities Operating surplus from continuing operations

13,942

13,977

11,569

11,846

Operating surplus of discontinued operations

13,942

13,977

11,569

11,846

16,621

16,470

16,207

16,145

4,896

(1,563)

(74)

Operating surplus Non-cash income and expense: Depreciation and amortisation Impairments Reversal of impairments

112

288

Interest accrued and not paid

Dividends accrued and not received

233

(Gain)/loss on disposal

(22,426)

(22,538)

1,626

(2,416)

(Increase)/decrease in Inventories

(504)

890

Increase/(decrease) in Trade and Other Payables

8,373

9,128

400

4,310

Increase/(decrease) in Other current Liabilities

3,463

(365)

203

220

1,214

1,197

(37)

(104)

18,301

18,765

36,809

37,046

182

230

333

336

(Increase)/decrease in Trade and Other Receivables

Increase/(decrease) in Provisions NHS Charitable funds – net adjustments for working capital movements, non-cash transactions and non-operating cash flows Other movements in operating cash flows Net cash generated from/(used in) operations Cash flows from investing activities: Interest received Purchase of Intangible assets Purchase of Property, Plant and Equipment Sales of Property, Plant and Equipment

(441)

(474)

(26,556)

(26,509)

(23,214)

199

139

(26,616)

(26,720)

(23,139)

(23,352)

Interest element of finance leases

(4)

(2)

Capital element of finance leases

(26)

Public Dividend Capital received

188

(8,167)

(8,263)

Cash from acquisition of subsidiary NHS Charitable funds – net cash flows from investing activities Net cash generated from/(used in) investing activities Cash flows from financing activities:

Public Dividend Capital dividend paid Net cash generated from/(used in) financing activities

(8,009)

(7,979)

(8,265)

(8,263)

Net increase /(decrease) in cash and cash equivalents

(16,324)

(15,934)

5,405

5,431

Cash and cash equivalents at start of year

61,028

59,914

55,623

54,483

Cash and cash equivalents at end of year

44,704

43,980

61,028

59,914

The Board of Directors approved the Strategic Report at a meeting held on 22 May 2014. Signed:

Auditor Independence The Trust has a policy in place for the engagement of external auditors for non-audit work. This policy complies with all relevant auditing standards and follows industry practice in terms of defining prohibited work and setting out the approval and notification processes all non-audit work should be subject to. The policy is reviewed annually by the Integrated Audit and Governance Committee; the Committee receives confirmation of compliance through regular progress reports from the external auditor.

Statement of the Chief Executive's responsibilities as the Accounting Officer of East Kent Hospitals University NHS Foundation Trust The NHS Act 2006 states that the Chief Executive is the Accounting Officer of the NHS Foundation Trust. The relevant responsibilities of the Accounting Officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by Monitor. Under the NHS Act 2006, Monitor has directed East Kent Hospitals University NHS Foundation Trust to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of East Kent Hospitals University NHS Foundation Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year. In preparing the accounts, the Accounting Officer is required to comply with the requirements of the NHS Foundation Trust Annual Reporting Manual and in particular to: • observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis • make judgements and estimates on a reasonable basis • state whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed, and disclose and explain any material departures in the financial statements • ensure that the use of public funds complies with the relevant legislation, delegated authorities and guidance; and • prepare the financial statements on a going concern basis. The accounting officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS Foundation Trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS Foundation Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor's NHS Foundation Trust Accounting Officer Memorandum.

Chief Executive Date: 22 May 2014

INDEPENDENT AUDITOR’S REPORT TO THE COUNCIL OF GOVERNORS OF EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST ON THE SUMMARY FINANCIAL STATEMENT We have examined the summary financial statement for the year ended 31 March 2014 set out in the annual report. This report is made solely to the Council of Governors of East Kent Hospitals University NHS Foundation Trust in accordance with Schedule 10 of the National Health Service Act 2006. Our audit work has been undertaken so that we might state to the Council of Governors of the Trust, as a body, those matters we are required to state to them in an auditor’s report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of Governors of the Trust, as a body, for our audit work, for this report or for the opinions we have formed. Respective responsibilities of directors and auditors The Directors are responsible for preparing the Annual Report. Our responsibility is to report to you our opinion on the consistency of the summary financial statement with the statutory financial statements. We also read the other information contained in the Annual Report and consider the implications for our report if we become aware of any misstatements or material inconsistencies with the summary financial statement. Basis of opinion We conducted our work in accordance with Bulletin 2008/03 “The auditor's statement on the summary financial statement in the United Kingdom” issued by the Auditing Practices Board. Our report on the statutory financial statements describes the basis of our opinion on those financial statements. Opinion In our opinion the summary financial statement is consistent with the statutory financial statements of East Kent Hospitals University NHS Foundation Trust for the year ended 31 March 2014 on which we have issued an unqualified opinion.

Philip Johnstone for and on behalf of KPMG LLP, Statutory Auditor Chartered Accountants 15 Canada Square Canary Wharf London E14 5GL 23 May 2014

quality report

What is a Quality Account? All providers of NHS services in England have a statutory duty to produce an annual report to the public about the quality of services they deliver. This is called the Quality Account. The Quality Account aims to increase public accountability and drive quality improvement within NHS organisations. They do this by getting organisations to review their performance over the previous year, identify areas for improvement and publish that information,along with a commitment to you about how those improvements will be made and monitored over the next year. Quality consists of three areas which are key to the delivery of high quality services: • How safe is the care we provide? (Patient Safety and Harm Free Care) • How well does the care we provide work? What are the outcomes of care? (clinical effectiveness) • How well do patients rate their experience of the care we provide? (Patient experience and person-centred care). This report is divided into four sections, the first of which includes a statement from the Chief Executive and looks at our performance in 2013/14 against the priorities and goals we set for patient safety, clinical effectiveness and patient experience. (Page 48)

Quality consists of three areas which are key to the delivery of high quality services.

The second section sets out the quality priorities and goals for 2014/15 for the same categories, and explains how we decided on them, how we intend to meet them, and how we will track our progress. (Page 56) The third section provides examples of how we have improved services for patients during 2013/14 and includes performance against national priorities and our local indicators. (Page 60) The fourth section includes statements of assurance relating to the quality of services and describes how we review them, including information and data quality. It includes a description of audits we have undertaken and our research work. We have also looked at how our staff contribute to quality. (Page 93) The annexes at the end of the report (page 126) include the comments of our external stakeholders including: • Our Commissioners (CCGs) • Healthwatch Kent • Council of Governors.

quality report Part 1 â&#x20AC;&#x201C; Statement on quality from the Chief Executive of the NHS Foundation Trust This Quality Account aims to assure our patients, commissioners and the local population that we continue to strive to deliver the highest quality of care. The Trust Board and our Governors are committed to providing safe, effective and high quality care for all our patients. In the Quality Account we outline the quality improvements that we plan to make over the next year (2014/15) and provide a retrospective check on how we did during 2013/14. The Quality Account celebrates the hard work and achievements of our staff and volunteers over the last 12 months. Underpinning this Quality Account and our ambition to improve is our Quality Strategy. This sets out our four quality objectives, which form the basis of everything we do. These are: to provide person-centred care and improve patient experience, to deliver safe care, to provide effective care and develop a workplace culture that enables and sustains quality improvement. To the best of my knowledge and belief the information in this document is accurate.

Chief Executive 22 May 2014

Section 1: How well did we do in 2013/14 in relation to the goals we set to improve quality? The Trust’s vision and mission remains as: Our vision is to be known as one of the top ten hospital trusts in England and the Kent hospital of choice for patients and those close to them. Our mission is to provide safe, patient focused and sustainable health services with and for the people of Kent. In achieving this we acknowledge our special responsibility for the most vulnerable members of the population we serve. As part of the ‘We care’ programme, over the last 18 months, 1,500 EKHUFT staff and patients have been describing what they think should be the values that we work to. The three values identified which have now formally been adopted by the Trust Board are: Our values We care so that: • People feel cared for as individuals • People feel safe, reassured and involved • People feel that we are making a difference

“Staff need to feel cared for to give care” “This is the closest description of how I would wish my patients to feel”

People feel cared for, safe and confident we are making a difference.

quality report Our Quality Strategy and how did we do in 2013/14? In 2013/14 we continued to build on the Quality Strategy implemented in 2012/13 which clearly sets out our quality ambition and priorities to improve the safety and effectiveness of patient care whilst continuing to develop and improve patient experience. Our strategy enables us to describe how we intend to improve continuously through a co-ordinated approach to delivery, improvement and governance. This includes additional areas for improvement, which were agreed with our lead commissioners, as part of the Commissioning for Quality and Innovation (CQUIN) Programme. Our Quality Strategy is built around our Shared Purpose Framework which has four key purposes: 1. Person-centred care and improving patient experience 2. Safe care by improving safety and reducing harm 3. Effective care by improving clinical effectiveness and reliability of care 4. An effective workplace culture that can sustain the above and enable quality improvement. The Figure below illustrates how we blend the achievement of our quality goals with the Trust values and the four purposes. Together these impact on the quality of the experience our patients receive. Figure 1: EKHUFT Shared Purpose Framework

Shared Purpose Framework – developed at EKHUFT as a tool to enable staff to connect their work to a shared vision. We care – how we deliver a great staff and patient experience: commitments, values and behaviours.

Value: SAFE People feel safe, reassured and involved

S a fe c a r e re

Effective workplace culture

are

Pe r s o n

-ce

tiv

nt r

Value: MAKING A DIFFERENCE

People feel confident we are making a difference

Eff

People feel cared for as individuals

care

A shared vision for patient and staff experience

6 Cs • Communication • Competency

Value: CARING

6 Cs • Care • Compassion

6 Cs • Commitment • Courage

Shared Purpose Framework

How we have prioritised our quality improvement initiatives

Our quality improvement initiatives are prioritised via the Trust’s annual objectives, which are informed by the Trust’s strategic objectives. The Shared Purpose Framework guides our quality priorities along with our We Care Trust values. Delivering on these areas delivers sustained improvements in the care and services we provide. For the year 13/14 examples of our priorities have focused on infection prevention and control, improving patient pathways through service improvement initiatives and seeking and acting on feedback from patients and users. In addition much work has taken place to develop an effective workforce, in numbers and expertise to provide a responsive person-centred culture. We have placed a large focus on developing the work-based culture to become effective as teams, enabling

our staff to flourish thereby delivering on our four purposes. These priorities are described in our Quality Strategy.

Through the development of our quality strategy we identified four priorities: Priority 1: Person-centred care and improving patient experience This priority is focused on delivering a high quality responsive experience that meets the expectations of those who use our services.

People feel cared for as individuals

What we said we would do in 2013/14 We aimed to make further improvements in patient experience during 2013/14 by putting patients first; listening and responding to the feedback they give: During 2013/14 we aimed to: • Implement the delivery plan in response to Francis Inquiry Recommendations • Implement the roll-out of “We Care” Programme, aim for all our multidisciplinary teams to be aware of the agreed values and for them to demonstrate values through improved behaviours and attitudes • Encourage patient and staff feedback through monthly “In your Shoes” and “In our Shoes” sessions • Improve awareness of our complaints process and ensure that 85 per cent of complaints and concerns are answered within one month, to the satisfaction of the complainant • Make Patient Opinion feedback available to the public and our staff through live feeds to our Trust website • Make compliments received available to the public and our staff by publishing on our Trust website • Make the Friends and Family Test available to 100% of adult inpatients and 100% of A&E patients and introduce the Friends and Family Test to our Maternity Units during the year. How did we do in 2013/14? • The delivery plan in response to Francis Inquiry Recommendations continues to be implemented. • Within the We Care programme, listening events involving over 1,500 patients and members of staff led to the Trust Values being identified and published. • The complaints process has been subject to a review this year and our response rate to complaints and concerns raised for the year showed an improving position from 83% to 88% being answered within one month, to the satisfaction of the complainant. • Patient Opinion feedback is responded to directly by the Chief Nurse or Deputy Chief Nurse. Live feeds to the Trust website are now in place. • Compliments received via Friends and Family patient feedback is regularly shared with our staff. • The Friends and Family Test is available to 100% of adult inpatients, A&E patients and in our Maternity Units. In March 2014 there was a patient response rate of 33% in inpatient areas, nearly 16% in A&E areas, and seven -26% in the different stages of maternity care.

quality report People feel safe, reassured and involved

Priority 2: Safe care by improving safety and reducing harm This priority is focused on delivering safe care and removing avoidable harm and preventable death.

What we said we would do in 2013/14 • Achieve the DH improvement trajectory for MRSA (Zero Tolerance for avoidable infections) and C. difficile Infections less than or equal to 29 post 72 hour. • Reduce avoidable hospital acquired pressure ulcers; category two by 25% and categories three and four by 50%. • Publish consultant level outcome data covering mortality and quality for ten surgical and medical specialities. • Reduce ‘Never’ events to zero. • Publish and reduce incidents where outcome is severe harm or death. How did we do in 2013/14? • Eight MRSA infections and 49 C difficile infections post 72 hours occurred. Each case was analysed in detail, using an RCA process and two of the MRSA bacteraemias were considered to be avoidable. Four were unavoidable and two were contaminants. Seven C. difficile cases were assessed as avoidable or there was non-compliance with Trust policy; 13 were unavoidable and compliant with policy, the remaining 28 were unavoidable but had some deficiencies in following policy. • There have been 95 avoidable hospital acquired Category two pressure ulcers which is within the target reduction of 25% from last year (no more than 131). Unfortunately the target to reduce Category three and four pressure ulcers by 50% was not achieved with instead an increase by just over 10% from 28 in 12/13 to 31 in 13/14. • Consultant level outcome information regarding a number of specialties has been published on the NHS choices website. A link to this has been provided on our Trust website for patients. Work is on-going to provide an in-house real time consultant dashboard linked to revalidation. • The Trust declared three never events in 2013/14; one is still being investigated and may not fulfil the criteria as a never event. • The number of serious incidents reported on STEIS are reported monthly in the Clinical Quality & Patient Safety Board report and themes from RCAs are published on a quarterly basis.

People feel confident we are making a difference

What we said we would do in 2013/14 • Achieve a reduction in crude mortality. • Achieve a HSMR of 75 by 31st March 2015. • Achieve a reduction in Summary Hospital Mortality Index by 31 March 2014. • Reduce unplanned re-admissions within 30 days of discharge by 0.65%. • Focus on improving readmission rate for patients with heart failure. • Achieve improvements required for the Enhancing Quality & Recovery Pathways. • Increase the proportion of patients receiving care through priority best tariff pathways. • Improve patient flow to reduce bed occupancy to 85 per cent +/- 2 per cent and to remove the need for unplanned extra beds by:• Optimising Hospital at Home; • Increasing % patients on ambulatory or short stay pathways; • Commissioning extra-capacity for step up and step down community beds/services (health and social care village) through reablement • Develop and implement an additional 10 ambulatory care pathways during 2013/14. • Increase the monitoring of PROMS responses in order to improve patient satisfaction with outcomes from surgery. How did we do in 2013/14? • There has been a reduction in crude mortality from 0.489 in 2012/13 for elective admissions to 0.3 in 2013/14, and from 30.95 in 2012/13 for non-elective admissions to 30.7 in 2013/14. • HSMR is currently at 79.5. • The latest published SHMI is for quarter 1 2013/14. This currently stands at 94.96%, which is below the national level of 100%; this is slightly higher than the performance for 2012/13. • The unplanned re-admissions within 30 days of discharge shows a performance in March 2014 of 8.02% against a target of 8.23%. The reported performance in 2013/13 was 8.91% for the same period last year. The year end position shows readmissions were 8.77% against a target to reduce readmissions overall. This was achieved. Clinical Case Review meetings take place to review readmissions of patients with Heart Failure. Key themes are being identified and an action plan created. • During the year the Enhancing Quality & Recovery Pathways have performed well and have exceeded targets set for Gynaecology, Hips & Knees, Colo-rectal and Heart Failure pathways. The pathway for Community Acquired Pneumonia (CAP) has improved significantly and is just under the target set (by less than 0.5%). It is anticipated that this target will be met. 53

quality report •

•

People feel cared for, safe and confident we are making a difference.

Work has taken place on the reporting of service provision within Best Practice Tariffs. Further work is planned to ensure a strong reporting process is in place to easily identify opportunities to increase the services provided within BPT pathways. Improving patient flow to reduce bed occupancy to 85 per cent +/- 2 % has not been consistently been achieved As at March 2014, bed occupancy was at 95.26%. Despite a number of initiatives being identified to enhance patient flow, key improvements such as internal waits and roles and responsibilities have not been fully embedded. External delays have increased substantially, particularly in relation to Continuing Health Care (average delay of 10 – 14 days) and Social Services: • Use of the Hospital at Home Service is being optimised, but the service has reduced from a 45 bedded virtual ward to 32 beds. • Health & Social Care Village – 60 beds have been commissioned in Care Homes (against a target of 80). A further 32 beds were identified during the tender process for Canterbury & Coastal CCG, but they were subsequently declined due to concerns re quality. All 60 commissioned beds have been fully operational since 31st January 2014 (20 beds were delayed, awaiting CQC Registration) • Current Activity for Zero LOS for Ambulatory was 32.76% for January against a target of 35%, with a stretch target of 40%. Current activity for Short Stay was at 66.6% in January 2014, against a target of 70%. Six Ambulatory Care Pathways have been developed, agreed, implemented and commissioned for 13/14 with the go-ahead for a further three to be implemented 13/14 -14/15 after further activity work has been completed. A process of reporting and governance of PROMS data to ensure that the data received is analysed and responded to has been identified and is being implemented.

Priority 4: An effective workplace culture that can enable and sustain quality improvement This priority is focused on developing a workplace culture that enables individuals and teams to deliver high performance, focused on patient-centred safe and effective care.

What we said we would do in 2013/14 • Establish a Quality Improvement & Innovation Hub to support staff in delivering person-centred, safe & effective care • Integrate the service improvement team and programme management office to align quality improvement, productivity and financial efficiency • Improve communication and engagement between senior management and staff • Increase the percentage of front-line teams that have completed the Aston Team effectiveness programme

• •

Make improvements to the staff appraisal process. Provide clinical leadership development based on shared purpose framework competencies to staff including doctors, nurses, and allied health professionals.

How did we do in 2013/14? • A Steering Group has led developing a Quality Improvement & Innovation Hub to support staff in delivering person-centred, safe & effective care encompassing the We Care values and behaviour programme. The “hub“ will provide in one place the support necessary to enable a critical mass of skills and expertise to be grown across the organisation and avoid duplication of resources and effort. • The integration of the Service Improvement Team and Programme Management office will be part of the Transformation Redesign Service Improvement Strategy and will be effective 01 May 2014. • The public Board meetings have included monthly sessions for staff to take a more active participation in the business of the organisation in order to improve communication and engagement between senior management and staff. Each member of the Executive team also has an allocated open door session for any member of staff to raise concerns or find out about any aspect of the Trust’s day to day business and ideas and plans for the future. • 130 teams, across all 5 Divisions, have completed the Team Based Working Programme. A sample of the Team leaders were asked to comment on the programme and 94% confirmed that they were able to state the difference that team based working had made to their team, would recommend Team based working to other team leaders and were continuing to using the team based working approach with their team. • The We Care Programme has included a review of performance appraisals. The full range of competencies and behaviours against “The Vision and Strategy for Nurses, Midwives and Care Staff”, the 6Cs, are included in the shared purpose framework for clinical staff and will become part of the staff appraisal discussion. • Over 50 staff have participated in the Clinical Leadership Programme, in 3 cohorts and this programme will continue at least twice yearly. Improved Appraisal effectiveness was completed for approx 50 Medical Consultant appraisers/re-validators. In addition Facilitating Individual Effectiveness rolling programmes, working towards leadership, are in place for 10-12 staff per site. A newly implemented Clinical Leadership programme for Medical Staff is in place. • Recruitment for consultants and other staff is now aligned with the We Care values. • Within the National Staff Survey, the Trust’s overall staff engagement score was 3.63 against a national average of 3.74. More details on the results of National Staff Survey can be found in the main body of the Annual Report.

quality report Section 2: Our annual quality objectives for 2014/15 It is our intention to use the same broad quality themes in 2014/15; these will be measured, monitored and reported in the same way as in previous years. The Trust’s annual objectives for 2014/15 are aligned with our Quality Strategy 1. Implement the third year of the Trust’s Quality Strategy demonstrating improvements in Patient Safety, Clinical Outcomes and Patient Experience / Person-Centred care, including implementing and monitoring the CQUINS Programme. 2. Develop and agree a Transformation Redesign Service Improvement Strategy that supports frontline staff to identify ways of working that cost less whilst maintaining high quality patient care 3. Embed patient, staff and public engagement into everyday practice in East Kent Hospitals University NHS Foundation Trust.

The specific priorities and objectives within the Quality Strategy for 2014/15 are:

People feel cared for as individuals

Priority 1: Person-centred compassionate care and improving patient experience by putting patients first This priority is focused on delivery of a high quality responsive experience to ensure that people feel cared for as individuals. We will strive to make further improvements during 2014/15 During 2014/15 we will: • Embed the recommendations from the Francis Report contained in our action plan so that they become business as usual; • Improve the care of clients who raise concerns or complaints and increase the number of compliments received; • Share patient feedback and make it available to public and staff through live feeds on the Trust website; • Improve the responsiveness to patient experience feedback and the embedding of feedback to improve patient experience; • Improve the essential aspects of nursing care with a focus on pain management, nutrition and hydration; • Embed the We Care values by monitoring National Inpatient survey feedback; • Embed engagement into everyday practice by increasing public, patient and carer involvement in internal decision making, developing our relationship with key local health economy stakeholders, vulnerable patient groups, minority communities and voluntary community organisations.

Priority 2: Safe care by improving safety and reducing harm This priority is focused on delivering safe care and removing avoidable harm and preventable death to ensure that people feel safe, reassured, and involved.

People feel safe, reassured and involved

During 2014/15 we will: • Further reduce HSMR, SHMI and crude mortality; • Publish consultant level data on mortality and quality for ten surgical and medical ; • Reduce ‘Never’ events to zero; • Reduce the recorded harm event rate as measured by the UK Trigger Tool model; • Improve infection prevention and control by zero tolerance of avoidable MRSA and achievement of trajectories for C. difficile and E. coli rates; • Improve the use of a Patient Safety Checklist for inpatients; • Reduce the number of falls resulting in harm; • Reduce the number of category 2, 3 and 4 pressure ulcers; the focus for the year is on the prevention of heel ulcers; • Increase Harm Free Care measured by the NHS Safety Thermometer to 95%; • Increase our achievement of openness and transparency, ‘duty of candour’.

Priority 3: Effective care by improving clinical effectiveness and reliability of care This priority is focused on increasing the percentage of patients receiving optimum care with good clinical outcomes, to ensure that people feel confident we are making a difference. During 2014/15 we will: • Respond to the findings of the March 2014 CQC visit and monitor improvements against action plan; • Increase the level of patient care delivered through Best Practice Tariff pathways; • Respond to Patient Reported Outcomes Measures (PROMS) to identify and implement areas of improvement; • Work in collaboration with community and social care providers to improve the pathways of care for patients with long term conditions who are over the age of 75; • Increase the number of patients following ambulatory care pathways; • Increase the number of our services available 7 days a week including extended therapy services; • Expand technologies to improve communication across primary and secondary care for patients; • Implement a £2.9 million investment into ward staffing and achieve the associated quality improvements for patients;

People feel confident we are making a difference

quality report •

• •

People feel cared for, safe and confident we are making a difference.

Display actual versus planned staffing levels on wards, report monthly to the board, publish on trust website and undertake six monthly staffing reviews; Reduce the number of avoidable unplanned readmissions; Ensure that where appropriate end of life conversations have been had with patients and carers that these are well documented, building on the establishment of an End of Life Board.

Priority 4: An effective workplace culture that can enable and sustain quality improvement This priority is focussed on enabling Quality Improvement by addressing:• Culture and Leadership • Staff Engagement • Resources to support improvement

During 2014/15 we will: • Clearly display information on nursing, midwifery and care staffing to patients and the public. • Support frontline staff to identify ways of working that cost less whilst maintaining high quality patient care. • Implement the Friends and Family Test to staff. • Enable quality improvement by addressing culture and leadership. • Embed engagement into everyday practice for our staff and for our patients. • Improve how we learn from patient feedback and clinical incidents; • Establish our Quality Improvement and Innovation Hub to support staff in delivering person-centred, safe and effective care and to improve services for patients; • Further roll out our Team Based Working Effectiveness programme; • Provide clinical leadership development based on our Shared Purpose Framework; • Embed the We Care values by monitoring and improving the National Staff and In-patient survey feedback.

Priority 5: Deliver improvements incentivised through Commissioning for Quality & Innovation (CQUIN) These are the priorities set by the local Clinical Commissioning Groups (CCGs) and National Specialised Commissioning clinical reference group (NHS England).

People feel cared for, safe and confident we are making a difference.

We have agreed the following national and local CQUIN areas for improvement with our commissioners:

National

Friends and Family Test

Implement to our staff and patients in Outpatient and Day Case areas, achieve required response rates and reduce negative responses in A&E areas.

National

NHS Safety Thermometer

Undertake improvement work to support achievement of required reduction in falls with harm, urinary tract infections in patients with a catheter and pressure ulcers.

National

Dementia

Sustain improvements in case finding, assessment and referral, increase training and evaluate carers involvement.

Local

Heart Failure

Achieve improvements in provision of high quality care through the Enhancing Quality Programme pathway.

Local

COPD

Improve appropriate referrals to the Stop Smoking Service and to the Community Respiratory Team

Local

Diabetes

Develop an integrated pathway in collaboration with other providers, agree outcome indicators and implement.

Local

Over 75s

Work in collaboration with CCGs and other providers in the development of an over 75s Frailty Pathway with the aim of reducing avoidable admissions.

Table 1: National & local priorities set by CCGs

The priorities for 2014/15 for the National Specialised Commissioning clinical reference group (NHS England) have not yet been finalised.

quality report Section 3: Examples of how we improved quality during 2013/14 In addition to activity directly aligned to the Trust’s Quality Strategy, many other achievements have taken place which are worthy of mention, and examples of these are described below.

Specific Quality Improvement Work we undertook in 2013/14:

People feel cared for as individuals

1. PERSON-CENTRED CARE AND IMPROVING PATIENT EXPERIENCE: 1. Patient and public involvement and the “We Care” Programme Foundation Trust members are invited to take part in meetings at which quality improvement is a key element of the agenda. We encourage feedback from Members, Governors and the Public. The Patient and Public Experience Team raises awareness of programmes to the public through hospital open days and other events The “We Care” programme has continued to move forward throughout 2013/14. Its aim is to improve the experience for patients and their visitors, as well as ensuring we look after one another. After listening to over 1500 patients and members of staff three new Trust values and behaviour standards have been developed. They describe how the Trust employees aim to interact with patients, family members and each other. These values and standards also outline the Trust’s ambition to “show that we care” and to provide an excellent experience for everyone who works within the Trust. They will become an integral part of the Trust’s working practices and will be used to guide staff recruitment and appraisal processes, illustrate how both patients and colleagues will be cared for, and how improvements in their experience will be measured. The values and standards are listed below. Each of these is evidenced through a more detailed description of the behaviours that staff and patients want to see. •

•

CARING: People will feel cared for as individuals – because we are welcoming and polite; attentive and helpful; we respect people, their dignity and their time, and we have the courage to speak up when things are not right. SAFE: People will feel safe, reassured and involved – because we are consistently safe and reassuringly professional, we listen and communicate clearly, and we work as an effective team. MAKING A DIFFERENCE: People will feel confident we are making a difference – because we take responsibility for delivering the best outcomes, act as leaders where we can, and we look to improve and develop ourselves and our services. In August a summer campaign was undertaken which focused on the mealtime experience, pain management, hand hygiene and seeking and giving feedback.

Events took place across the Trust during October by frontline staff. These have sought feedback from patients and families, as well as having discussions about the We Care values within teams. The Steering Group are currently working on the development of the We Care Programme going forward. This includes designing a Trust wide organisational development plan and embedding the values and behaviours into everyday practice. We have undergone a “branding” piece of work that ensures our communications with each other and the public are empathetic and sensitive. This has been labelled the ‘Tone of Voice’ work led by Human Resources. In addition, work is in progress to embed the values as part of job advertisements, the recruitment process, and our engagement with staff. The roll out of the “We Care” Champions has commenced following the approval by the Board of Directors of the Trust values. More events took place in March to engage staff and patients in the delivery of the values. Several “Market Place” events have occurred across the Trust; this enables staff to integrate with users of our services, to obtain feedback on their experiences and to capture areas for improvement. 2. Eliminating mixed sex accommodation All NHS providers are required to undertake a self assessment of their provision for same sex accommodation, using the Department of Health’s checklist of standards. A declaration of compliance or non compliance must then be provided. Throughout the year we have declared compliance with the mixed sex sleeping accommodation standards. We report the number of occasions and number of patients affected even if mixing does occur within the agreed clinical scenarios that protects patient safety and maintains the best interests of the patient. We are currently refreshing our mixed sex accommodation policy and updating the agreed clinical scenarios to better reflect those set out in the 2010 guidance. These are being worked up collaboratively with our CCG colleagues and will be agreed together. Improvements are also in progress to provide improved bathroom and toilet facilities for patients in the Clinical Decision Unit at Kent & Canterbury Hospital. This will ensure maximum privacy and dignity for those patients. Our latest compliance statement can be found on our website at: www.ekhuft.nhs.uk 3. Improving hospital food During 2013/14 the Trust has embedded its catering contract, which began its introduction in July 2012. Over the past year improvements in service have continued and patients have remained at the centre of decision making processes in order to ensure that all patients receive high quality meals in all our acute hospitals wherever they are in their patient journey. The key improvements over the past year are: • All kitchens have been refitted on all wards with new ovens, equipment, cupboards and worktops; • The main menu has already been reviewed once and is in the process of being reviewed for a second time. Latest improvements planned are to increase the number of dishes with a high calorie content;

quality report •

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• •

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The choice of 12 snacks of sweet, savoury or fruit options which is provided three times per day has been reviewed with patients and Governors. Feedback was acted upon and included the introduction of bars of chocolate and plainer biscuit options within the snack choice; Blue crockery has been implemented with buffet style finger foods for those patients with advanced dementia who are unable to use cutlery. Patients with advanced dementia can often not differentiate shades of colour, so mashed potato on a white plate, or tomato on a red plate, can be difficult to see. The blue plates create a contrast colour for all the food, making it easier to see; Menus for puree, soft and mashed options have been developed and will be reviewed over the coming year; The Housekeeper Service has been implemented on all wards. Further reviews have suggested that some Housekeepers need further training and this is currently being implemented for all Housekeepers across the Trust; The evening soup option is being reviewed currently and the 21 day menu cycle will be reduced to ensure we provide only soup that is popular to our patient groups, rather than the current wider range which includes those that are less popular.

During 2014/15 we plan to continue to review our food service and continue to make improvements where required. This will include reviewing all of our menus, including children’s menu, sandwiches and the main hot meals of the day. At every opportunity we will endeavour to utilise our patients and public in the decision making processes. During Nutrition and Hydration Week 2014 we held the most recent of our three public engagement events on nutrition. The feedback is currently being collated, but there was overwhelming support to reintroduce toast. This will be something that will need to be reviewed over the coming year as it has implications for our fire risk rating. Once our main menus have been agreed, we intend to launch our Picture Menus for those who have difficulties communicating or reading from the menu. We have already consulted with different patient and carer groups and have had widespread support. 4. Patient Led Assessments of Care Environments (PLACE) Patient Led Assessments of Care Environments (PLACE) provides a framework for inspecting standards to demonstrate how well individual healthcare organisations believe they are performing in the following key areas: • cleanliness; • food, • privacy and dignity; and • general maintenance/décor. The PLACE audit for 2013/14 required the Trust to submit results from each hospital site, rather than as an overall Trust. Action plans were then implemented on a site focused basis following the findings. A PLACE Steering Group has been established to address the actions, led jointly by the Deputy Chief Nurse/Deputy Director of Quality and the Assistant Director of Estates. Results and action plans from each site will be drawn together and Trust-wide priorities and actions and developed into a consistent programme.

The Steering Group is also considering use of additional informal sample PLACE self-assessments during the year, subject to the availability of suitable patient volunteers, to help reinforce on-going improvements. 2013/14 RESULTS

East Kent Hospitals average score (%)

National Average Score (%)

Cleanliness

85.53

95.74

Condition, Appearance and Maintenance

81.38

88.75

Privacy, Dignity and Wellbeing

86.6

88.87

Food and Hydration

89.07

84.98

Table 2: PLACE results 2013/14

5. The NHS National Inpatient Survey 2013 All NHS Trusts in England are required to participate in the annual adult inpatient survey which is led by the Care Quality Commission (CQC). The survey provides us with an opportunity to review progress in meeting the expectations of patients who are treated by us. The inpatient survey results are collated and contribute the CQC’s assessment of our performance against the essential standards for quality and safety. The inpatient survey was conducted during the end of 2013 and was sent to 850 patients who were admitted to hospital for a stay of one night or more. The survey asked a range of questions in the following categories: • The Emergency department • Waiting list and planned admissions • Waiting to get a bed on a ward • The hospital and ward • Doctors • Nurses • Care and treatment • Operations and procedures • Leaving hospital • Overall views and experiences. Survey statistics for East Kent Hospitals University NHS Foundation Trust show the following: • 405 patients completed a questionnaire • More women than men completed the survey, (52 per cent in comparison with 48 per cent). • Patients aged 66 and over made up the largest group of those who responded (64 per cent).

quality report The table below compares our performance with the average from 155 other Trusts that complete these surveys. The table outlines the high level categories and there are 70 specific questions in the full questionnaire.

Table 3: National in-patient survey results Question

2011 (%)

2012 (%)

2013 (%)

Improvement/ deterioration

2013 National Comparison

The Emergency/ A&E Dept

Same

About the same

Waiting list and planned admissions (answered by those

6% deterioration

About the same

Waiting to get to a bed on a ward

3% deterioration

About the same

The hospital and ward

Same

About the same

2011 (%)

2012 (%)

2013 (%)

Improvement/ deterioration

2013 National Comparison

Doctors

1% deterioration

About the same

Nurses

Same

About the same

Care and treatment

1% improvement

About the same

Operations and procedures

1% improvement

About the same

Leaving hospital

3% improvement

About the same

Overall views and experiences

7% improvement

About the same

(answered by emergency patients only)

referred to hospital)

Question

(answered by patients who had an operation or procedure)

The Survey results demonstrate that the Trust continues to perform against National average in providing a good level of patient experience. The Trust continues to identify where further improvements can be made and specific plans can be seen in the 2013/14 action plan detailed further opposite.

In response to the 2012 Survey, our priorities for improvement during 2013/14 were:Improvements planned for 2013/14

Action taken

1. Implementation of a Friends & Family Test to A&E, Inpatient Areas and Maternity

We introduced the Friends and Family Test in April 2013 for inpatients and A&E attendees. In October 2013 we introduced the Maternity Friends and Family Test.

2. Reporting via the Ward Quality Dashboard the results of the Patient Friends & Family Test, regular inpatient survey results (via the Meridian system) and the number of complaints, to pro actively identify areas of concern;

The Friends & Family Test results are published to all participating areas on a monthly basis. Complaints information is also provided to each Division. Information on both the Friends & Family Test and Complaints are reported monthly via the Clinical Quality & Patient Safety Board Report.

3. Reviewing the literature available to patients on “How to Complain”;

The information available on how to complain has improved, leading to an improved result in this year’s survey of 30 against a score of only 18 in 2012.

4. Launching the second year of the “We Care” Programme.

The “We Care” programme has continued to move forward throughout 2013/14 and has led to the introduction of the Trust Values; • Caring • Safe • Making a difference.

Table 4: Improvements planned

Our priorities for improvement during 2014/15 will include plans to address the areas where results of the National Inpatient Survey have deteriorated since 2012/13, or are lower than anticipated, to ensure that patient experience can be improved.

quality report 6. Responding to feedback through Patient Opinion and NHS Choices Patient Opinion and NHS Choices are independent websites enabling patients to register feedback on the service they have received. They provide a simple web based method of providing comments and feedback to the Trust. These comments are widely read by staff and acted upon. Feedback is used to make improvements and also shared with staff to encourage or develop actions to address concerns. Comments posted on Patient Opinion are read and answered by the Chief Nurse and Director of Quality and Operations. Often this necessitates actions by the Trust to resolve the concern raised by the patient or their visitor. The feedback is considered in conjunction with complaints, concerns and compliments received through other routes in order to drive up quality of care. The Trust has received 350 comments via the Patient Opinion website between April 2013 and March 2014, and responded to 97% of these comments. Examples of recent feedback received:“Would not get better treatment in Harley Street! Everybody I came in contact with first class in everyway, from reception to Surgeon.” Posted by Malcolm Beacock, about The Kent & Canterbury Hospital, March 2014

“Was admitted to surgical admissions for thyroid operation with overnight stay. My care from start to discharge was excellent. I also attend Rheumatology on a regular basis and again care is excellent.” Anonymous, about The William Harvey Hospital, Ashford, February 2014

“On my arrival staff had difficulty finding a record of my appointment. The radiographer didn’t say hello or introduce herself to me, wasn’t friendly and demonstrated little empathy/sympathy for my condition. Despite being a new building the waiting rooms in particular and to a lesser extent the rooms used for ultrasounds are shabby/depressing.” Anonymous, about Queen Elizabeth The Queen Mother Hospital, Margate, March 2014

“I have recently been discharged from Quex ward at the QEQM Hospital in Margate, Kent. I cannot praise the staff highly enough – from the cleaning and catering teams to the nurses, doctors and physiotherapists. They were all very helpful and lovely to be around. The food was much better than expected, after all you hear in the news it was a pleasant surprise! The ladies and gents on the catering and cleaning team were very informative and kept the cleanliness of the ward to a very high standard. Please pass on my thanks to all.” Posted by lookedfterwell (as the patient) about The Queen Elizabeth The Queen Mother Hospital / Trauma and orthopaedics, Margate, March 2014

“We have had all of our three children at William Harvey Hospital. All three have had conditions requiring extended stays in hospital and we cannot fault the professionalism and care given by the staff there. However despite ‘proud’ signs declaring the hospital smoke free there are still numerous people smoking on the common walkways from the car park and around hospital entrances. The smell of this even finds its way inside.” ”Posted by WWF (as a parent/guardian), February 2014

7. Safeguarding adults and children Safeguarding vulnerable adults and children is an important part of the way we deliver care to our patients. Protecting children Safeguarding children continues to be an important part of our delivery of care to all our paediatric patients. The range of safeguarding activity being undertaken by the team continues to diversify and expand as it adapts to support both the local and national safeguarding agenda. In addition, the level of complexity of cases being held by staff members continues to place increasing demand for supervision and training for these individuals. Whilst the team is able to provide a quality and proactive service in relation to safeguarding children, in order for this level of service to continue, evidence is being gathered to demonstrate the need for expansion of the team. Over the past year we have seen an increase in growth in activity relating to safeguarding. The recently released working Together to Safeguard Children 2013 (DoH 2013) clearly defines our responsibilities to safeguarding children. Safeguarding activity undertaken to give assurance that the Trust is meeting its responsibilities include:• Safeguarding Children Supervision • Consultation with Safeguarding Children Team • Completion of health record chronologies for court proceedings • Flagging on PAS system • Participation in a Domestic Homicide Review (DHR) and briefings for KSCB Serious Case Review panels • Supporting partner agencies in relation to Child Sexual Exploitation and trafficking In 2013/14: • The Safeguarding Children Team received 1,453 consultations, the majority of which were from staff within the Trust, who were concerned about a vulnerable child or family in their care, compared to over 1,300 in 2012/13. Staff continue to manage complex cases and require high level of support. The team continue to quality assure all copies of referrals made to Social Services that are received by the team. • The team are working with relevant management in order to identify Link Paediatric Nurses and Midwives across the Trust in order to provide a method for dissemination of information and provide a more seamless service. • The electronic flagging system on PAS for all children subject to child protection plans has been expanded to include mothers whose unborn babies are subject to plans. This ensures improved communications between health and other relevant agencies. The flagging system has proved to be invaluable, particularly in the sharing of appropriate information with other agencies in order to safeguard the children and their families. • The Common Assessment Framework (CAF), which has been implemented to provide early intervention for those children and their families who require support from other agencies, continues to be promoted within the Trust. The emphasis in the next financial year will not be on numbers of CAFs produced but the quality and outcome for the children and their families. 67

quality report •

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The Concern and Vulnerability Form used by midwives when they have identified vulnerable indicators within a family, was used nearly 900 times, a significant increase from the previous year. The team of 15 Child Protection Supervisors have provided Child Protection Supervision for 299 members of staff, an increase from 245 in 2012/13.

Protecting adults The Adult Safeguarding team continues to support doctors, therapists and matrons across each of our three main hospital sites and two community hospitals, in all matters relating to safeguarding and the protection of people’s human rights. They work closely with the Dementia, Nutrition and Tissue Viability teams to improve the quality of care for patients and ensure that it is person centred. Unlike children, adults have the ability to give lawful consent. Consent is a fundamental part of adult Safeguarding and an important part of clinical care. The Mental Capacity Act is the legislation that underpins the human rights of any person who is temporarily or permanently lacking in capacity and therefore unable to give informed consent to care or treatment. This year the Adult Safeguarding team has focused on teaching medical and nursing staff about the Act and its implications within clinical care. To support this work, Kent County Council provided a specialist trainer, to improve the scope for training. This has proved an effective initiative, resulting in an increase in the number of referrals to the Independent Mental Capacity Advocates (IMCAs) a rise in Deprivation of Liberty applications (DoLs) and an increase in requests for support for the Best Interest processes. Overall, staff have a heightened awareness of the team and their role. The number of staff who have undergone safeguarding training continues to grow, with a significant improvement in the engagement of doctors. The number of Adult Protection alerts raised by staff, as a result of observation, patient disclosure, or self reporting has also increased significantly. Some key highlights from 2013/14 are outlined below: • A range of flow charts have been designed and issued to wards, to help with decision making and record keeping, for those vulnerable adults, who lack mental capacity. • Work with social services, community providers and EKUHFT Tissue Viability team has informed and improved the system’s understanding of “unavoidable” and “avoidable” pressure ulcers, reducing the number of inappropriate safeguarding alerts. • The SMART + pilot has commenced. Its purpose is to provide a systematic, informative pathway for the identification, tracking and monitoring of care, for vulnerable adults who may lack mental capacity whilst in EKUHFT’s care. The tool has been designed in collaboration with our mental health liaison team. The document is designed to demonstrate person centred care and offer clinicians guidance and support. • The team has worked with stakeholders to introduce an electronic referral system for raising of alerts, IMCA referrals and DOLs applications. This has improved the teams’ ability to track and monitor cases and cross reference with the DATIX incident reporting system. • We have managed 61 Adult Protection Alerts where concerns have been raised about vulnerable adults

Learning disability Over the last 12 months we have progressed our understanding of how people with learning disabilities use East Kent Hospital services compared to the general population. People with learning disabilities are 5 times as likely as members of the general population to be admitted via non elective pathways and 4 times as likely to experience readmission. In collaboration with the Community Learning Disability Teams we have published the Learning Disability Repeated Admission Pathway – www.ekhuft.nhs.uk/ldra which in 2013 produced a 5% reduction in readmission in this group. This repeated admission pathway is dependent on staff identifying people with learning disabilities and knowing how to review the number of times they have been admitted. We have worked with a software company to test an Apple™ application for alerts of admissions of people with learning disabilities coming straight to a mobile device. The Trust was shortlisted for the Patient Safety Improvement Award at the Nursing Times awards 2013 for its work to reduce readmissions, and specially commended for the same work in the RCN Publishing’s Nurse Awards in 2013. The Trust has developed a Framework for making reasonable adjustments under the Equality Act 2010. The 4 Cs as they are known refer to Communication, Choice Making, Collaboration and Coordination. This framework encourages staff to use the hospital communication book and My Healthcare Passport, assess capacity, and work effectively with family and carers. The Trust published research in 2013 based on Bright Futures. Bright Futures is an internship project led by the Human Resources Team to bring more people with learning disabilities in the workforce. The research project identified staff attitudes to working with people with learning disabilities, and found that these knowledge, skills and advanced communication skills would improve the service for patients in the future. An action research project is about to commence in East Kent looking at the implementation and evaluation of My Healthcare Passport, a tool to enable Trust staff to work more effectively with people who might not be able to verbalise easily the full range of their problems. 8. Compliments, concerns, comments and complaints (the 4 Cs) Patients and their carers who raise concerns and complaints following an episode of care or treatment they receive give us an opportunity to learn and improve our services. The Trust’s process for managing the 4 Cs is strongly patient-focused and based on the Parliamentary and Health Service Ombudsman (PHSO) six principles for good complaint handling: • Getting it right; • Being customer focused; • Being open and accountable; • Acting fairly and proportionately; • Putting things right; • Seeking continuous improvement. 69

quality report The 4Cs programme is managed by the Patient Experience Team (PET) in conjunction with Divisional Teams. During 2013/14 the PET dealt with 894 formal complaints, 3,521 informal contacts (raising concerns or sign posting) and over 16,440 compliments. Activity for the last four years is highlighted in the table below: Date first received

Table 5: Complaints summary

2010/11

2011/12

2012/13

2013/14

735

691

768

894

Informal contacts received

3,923

3,150

2,729

3,521

Compliments received

11,157

18,478

15,391

17,076

Total number of formal complaints received

The total number of informal concerns has increased by 29% from the previous financial year (2,729 in 2012/13 compared to 3,521 in 2013/14) and the formal complaints by over 16%. We believe this has been driven in part by the recommendations contained within the second Francis Report and the associated media attention into NHS services. The number of compliments has increased by 7% for 2013/14 in comparison to 2012/13 (15,391 for 2012/13, 17,076 for 2013/14). Year received

Table 6: Response time for formal complaints

Percentage first response received by the complainant within agreed time

2010/11

2011/12

2012/13

2013/14

It takes us approximately 41 working days for us to investigate a complaint fully, very often we need to obtain information from other organisations which can delay the process. During 2013/14 nine per cent of complainants who had received their first response remained unhappy and sought further clarification which is an increase from 9 per cent last year. The PHSO opened 33 complaints relating to the experience of our patients; they have formally investigated 24 cases. The PHSO upheld nine cases, four remain outstanding and 11 were closed without further issues being raised. We achieved over 20 compliments for every one complaint we received, this exceeded our target for 2013/14 of 12 compliments for every one complaint we received. 70

9. Innovation The Trust prides itself in being a leader in Innovation, and embracing opportunities to utilise technology, to improve patient care and communication. During 2013/14 there have been many examples of this including:• Developed from within the Information Directorate within the Trust beautiful information now includes links with a number of private and academic partners. It focuses on providing an advisory service, Information management services, channeling intellectual property (innovation incubator) and support services for improved clinical coding. It won the Data/Information Management Award within the Patient Safety Awards 2013 and further information can be found on the website http://www.beautifulinformation.org. • Carpal Tunnel Syndrome website The innovative web-based screening technique uses real time artificial intelligence to analyse data input by patients, cutting the number of unnecessary appointments and tests for Carpal Tunnel Syndrome. Traditionally, diagnosis and treatment of Carpal Tunnel Syndrome could involve multiple visits to GP, outpatients and neurophysiology. The online questionnaire can assess the likelihood of Carpal Tunnel Syndrome in a few minutes at home and act as a pre-clinic assessment and guide to further management. This can reduce referrals of patients with other disorders to the Carpal Tunnel Syndrome clinic and help to identify patients who are likely to have severe Carpal Tunnel Syndrome quickly. The Trust team worked in collaboration with City University London, and Manchester University, and the project was awarded an NHS Innovation Challenge Prize in 2013. Further information can be found on the website http://www.carpal-tunnel.net/. • Telehealth The Trust has introduced the use of Telehealth for a small number of patients to trial the benefits and understand how best to apply it. Telehealth involves providing technology within a patient’s home to enable them to regularly submit information about their medical condition to the Trust via the equipment. This enables clinical staff to monitor the patient’s condition, and respond with advice where appropriate without requiring the patient to attend hospital. The use and benefits of Telehealth will continue to be reviewed within the Trust. • Community Service redesign A project between the Trust and Ashford CCG to give care home patients an alternative to hospital admission won a National HSJ Efficiency in Community Service Redesign Award in 2013. • Board Leadership The Trust’s Board was awarded the HSJ Patient Safety Awards 2013 for Board Leadership for demonstrating successful implementation of the strategy and plan to improve continuously patient safety. • Endoscopic Capsule Camera The Trust has introduced the use of Endoscopic capsule cameras as a procedure to reduce the need for invasive surgery. • Careflow Project A system is in place so that when a renal patient attends one of our emergency departments, an alert is sent through to the Renal Team. This is being reviewed to identify where a similar approach could be effective for other patient groups. 71

quality report People feel safe, reassured and involved

2. SAFE CARE â&#x20AC;&#x201C; IMPROVING SAFETY AND REDUCING HARM: Patient Safety Patient safety remains the core focus of the Trust, the Board of Directors and the divisional leadership teams. The Board won the Patient Safety Awards in 2013 for Board Leadership for demonstrating successful implementation of our strategy and plans to improve continuously patient safety. The following areas are examples of the initiatives and goals for patient safety we use to improve performance. 1. Reducing Falls Keeping our patients safe when they are in hospital is an important priority for us. With an increasingly frail and elderly population, who often have multiple clinical needs, it is essential that we do all that we can to reduce the risk of falling. Although there have been more falls, and more falls resulting in fractures, over the last year, data for the past five years shows a downward trend in the number of falls in total and falls resulting in fractures . Over the coming year a proposed Safety Thermometer CQUIN target will be aimed at reducing harm from falls. Areas for action are full implementation of the new Falls Risk Assessment and Care Plan, compliance with link worker mandatory training, and compliance with the risk assessment (focus on assessment and management of postural hypotension and strength and balance assessment and exercise interventions). Alongside this the Harm Prevention Action Group are beginning to plan educational awareness events to inform frontline staff of the need to consider all â&#x20AC;&#x153;risksâ&#x20AC;? to the patient as many patients have multiple risks. For example, patients with Dementia are more likely to fall and are also more prone to nutritional problems whilst patients with movement problems have an increased risk of pressure ulcers.

Figure 2: Patient falls EKHUFT: Number of Injurious and Non-injurious Falls Apr-10 to Mar-14 700 600

Number of Falls

500 400 300 200 100 0

Q2 2010

Q3 2010

Q4 2010

Q1 2011

Q2 2011

Q3 2011

Q4 2011

Q1 2012

Q2 2012

Q3 2012

Q4 2012

Q1 2013

Q2 2013

Q3 2013

Q4 2013

Q1 2014

None

373

328

374

339

293

304

306

351

295

316

309

391

335

310

313

304

Low

199

160

166

159

169

141

144

131

170

195

178

207

211

212

204

Moderate

Severe

Death

Total

624

568

587

561

520

503

526

558

489

534

507

612

562

543

527

524

Patient falls resulting in moderate harm and above Overall, there has been a decrease in the more serious injuries over the past five years as shown in Figure 2.

Figure 3: Patient falls resulting in harm EKHUFT: Number of Falls of Moderate Severity or Greater Apr-10 to Mar-14 100

Number of Falls

80 60 40 20 0

Q2 2010

Q3 2010

Q4 2010

Q1 2011

Q2 2011

Q3 2011

Q4 2011

Q1 2012

Q2 2012

Q3 2012

Q4 2012

Q1 2013

Q2 2013

Q3 2013

Q4 2013

Q1 2014

Moderate

Severe

Death

Total

quality report The way we should assess falls risk was changed after publication of NICE Guidance on Prevention of Falls in Older People in June 2013. This has led to an in-depth consultation programme where the Falls Link Workers have worked with the Falls Team to develop a new Falls Risk Assessment and Care Plan. This concentrates on falls prevention and has a clearer plan for actions after risks are identified. A major part of our action plan involves education around falls prevention on wards using a cascade system involving all members of the Falls Team and Falls Link Workers. The new tool is now fully implemented but there is on-going review and education. During 2013/14 we have: • Carried out a Trust wide falls screening and intervention audit to identify any further improvements required; • Introduced and updated a Falls Risk Assessment and Care Plan; • Carried out open training sessions focusing on falls screening, incidence reporting and the post falls protocol; • Conducted detailed investigations of our most serious falls to ensure that lessons are learnt and changes to practice can be delivered throughout the organisation; • Commenced work with the newly formed Harm Prevention Action Group to triangulate incident data, collaborate on Root Cause Analyses, streamline the risk assessment booklet and work jointly with audit to drive up standards; • Utilised the incident reporting system to identify equipment availability problems: • Introduced non slip socks to ward areas. Next steps As part of our quality improvement programme and given our investment in harm prevention strategies we have identified that some additional work is required to achieve a further reduction in the number of falls that result in a fracture; • Review compliance with and the quality of assessment using the Falls Risk Assessment and Care Plan; • Improve link worker compliance with mandatory falls prevention training; • Improve the assessment of and medical management of postural hypotension; • Increase the number of evidence based gait and balance assessments carried out; • Increase the number of patients receiving evidence based strength and balance exercise interventions.

2. Reducing avoidable hospital acquired pressure ulcers Pressure ulcers represent a major burden of sickness and reduced quality of life for patients and create significant difficulties for patients, their carers and families. Pressure ulcers can occur in any patient but are more likely in high risk groups such as the elderly, the overweight, malnourished and those with certain underlying conditions.

During 2013/14 we have continued to make quality improvements achieving 25% reduction in avoidable category 2 pressure ulcers in line with agreed trajectory. However, we did not achieve our target of 50% reduction in deep ulcers, categories three and four. Each incident has been fully investigated and those avoidable ulcers, mainly occurring at the heel, were largely due to insufficient pressure relief at the sacrum and heel. Further actions have been agreed to address these learning points.

Figure 4: Category 2 Pressure Ulcer incidence against trajectory EKHUFT: Pressure Ulcer (Category 2) Incidence Quality Strategy Trajectory 2013/14 160

Pressure Ulcer (Cat 2) Number

140

25% Reduction

120 100 80 60 40 20 0

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

2013-2014 Avoidable

2013-2014Cum Avoidable

2012-2013Cum Avoidable

106

124

143

151

2013-2014Cum Trajectory

106

113

Figure 5: Category 3 & 4 Pressure Ulcer incidence against trajectory EKHUFT: Pressure Ulcer (Category 3 & 4) Incidence Quality Strategy Trajectory 2013/14

Pressure Ulcer (Cat 3 & 4) Number

35 30 25 50% Reduction

20 15 10 5 0

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

2013-2014 Avoidable

2013-2014Cum Avoidable

2012-2013Cum Avoidable

2013-2014Cum Trajectory

quality report In support of our programme to reduce hospital acquired pressure ulcers, during 2013/14 we have: • Reduced the number of avoidable superficial (category 2) ulcers by 37% against a 25% improvement trajectory. • Strengthened leadership of our Pressure Ulcer strategy through the Pressure Ulcer Steering group; • Implemented and improved our Trust wide action plan; • Developed specific actions plans for Medical and Stroke wards; • Implemented the SKINs bundle on all general wards; • Delivered regular education and training to all staff groups as required, including link nurses and ward based training; • Increased the Tissue Viability team with an additional nurse specialist, improving availability at each acute hospital site; • Identified and raised awareness of learning points from reported incidents; • Undertook project work with the Medical Devices Beds and Mattresses sub-group to review and improve our pressure redistributing equipment strategy; • Introduced electronic referrals to tissue viability team to improve timely processes. Next steps – During 2014/15 we will: • Work to eliminate heel ulcers and avoidable deep (category 3 and 4) ulcers. • Complete project work in conjunction with the Medical Devices Beds and Mattresses sub-group, to include equipment trials and develop a local equipment library to update and improve service. Review the equipment available for patients at risk from developing heel ulcers. • Work with individual ward managers and matrons to develop specific ward based action plans with individual ward improvement trajectories. 3. Reducing Venous Thromboembolism (VTE) Venous Thromboembolism (VTE) is a significant cause of death, long term disability and chronic ill health. Reducing its incidence has been recognised as a clinical priority for the NHS. Our improvement programme aims to improve the percentage of all adult inpatients who have a VTE risk assessment on admission to hospital using the national tool. The national target is now 95 per cent. During 2013/14 the National target for patients risk assessed for VTE was increased to 95% and achieved. We also developed a process for undertaking detailed investigations (RCAs) of patients who develop a VTE related to their hospital stay (known as Hospital Associated Thrombosis – HAT) to ensure that lessons are learnt and changes to practice can be delivered throughout the organisation. This process was also recognised nationally and resulted in specific CQUIN targets, set locally at 60% completion within three months. This has been achieved to date. In support of our programme to reduce the risk of venous thromboembolism, during 2013/14 we have: • Improved the quality of data recording and reporting for Trust wide VTE incidents and HAT, setting baselines for comparison with local & national guidance;

•

• •

•

Continued monthly audits of the use of VTE prophylaxis to enable monthly reporting of performance against Trust and national guidance; continuing to show improved performance; Introduced VTE Champions, to promote individual members of staff whom show excellence in VTE prevention within their role; Trust wide replacement of all Intermittent Pneumatic Compression Devices (IPCD) ‘leg & foot pumps’ in theatres, ITU & surgical wards. This is an essential aspect of non-pharmaceutical VTE prevention; VTE Staff training programme: at induction, mandatory eLearning (for clinical staff), specific training for healthcare assistants, preceptorship nurses and junior doctors.

Next steps – During 2014/15 we will • Work to sustain all risk assessment and HAT RCA achievements; • Focus on developing VTE prevention exemplar status (in-line with nationally recognised criteria); • Introduce a programme of link nurses/ workers on wards to promote VTE best practice; • Develop and embed IPCD in stroke wards (in line with the CLOTS 3 study); • Ensure a robust process is in place for ensuring action planning and lessons learned from RCAs of HATs is embedded into Trust and Divisional governance systems.

4. Identification and management of deteriorating patients VitalPAC is an innovative software system, which allows doctors and nurses to record clinical data on handheld devices at the bedside, analyse it instantly, and automatically summon timely and appropriate help. VitalPAC therefore enables clinicians to more easily identify deteriorating patients on wards across the Trust. VitalPAC is currently in use on 46 adult in-patient areas within the Trust. In addition, VitalPAC devices have been rolled out across all anaesthetic rooms on two of the main sites. This enables clinicians to accurately complete a VTE risk assessment at the end of anaesthetic time. There has been a short pilot of VitalPAC in the Majors and Resuscitation areas in A&E at the William Harvey Hospital, Ashford. This has now ended and a review is taking place regarding a full rollout to all A&E areas. Next steps – During 2014/15 we will: • Review the pilot of use of VitalPAC in A&E at Ashford; • Extend the use of VitalPAC into the ambulatory care units on all three sites; • Pilot a fluid management module of VitalPAC in three wards; • Pilot escalation of care messages and the early identification of the deteriorating patient to doctors using VitalPAC working in conjunction with multi-tone bleeps; • Extend the use of reporting from VitalPAC to monitor compliance of VTE assessments and to provide performance data.

quality report 5. The WHO Safer Surgery Checklist The WHO Safe Surgery Checklist was introduced as part of the Safe Surgery Saves Lives initiative. The aim of the checklist is to aid operating theatre teams to reduce the numbers of adverse incidents in this area. Compliance with completing the WHO Safe Surgery Checklist for 2013/14 is 97 per cent for the period March 2013 to January 2014, compared to 99% in 2012/13. However, a new process for recording the use of the checklist was introduced in 2013/14 and reporting is expected to further improve in 2013/14. Next steps – During 2014/15 we will • Train staff to be able to record the use of the WHO Safe Surgery Checklist directly, to improve reporting of its use; • Continue to regularly report and monitor the use of the WHO Safe Surgery Checklist.

6. Executive Patient Safety Visits Programme The Executive Patient Safety visits programme started in April 2009. The Trust Executive Directors lead the patient safety visits, which involve talking to frontline staff about patient safety and other issues that staff may want to discuss. Specific themes or actions to follow-up are reviewed at the Patient Safety Board. All our Executive Directors and patient safety team take part in the patient safety visits; the Non-Executive Directors and the Governors also participate. The goals of the Executive Patient Safety visits are to: • Increase awareness of safety issues among all staff; • Make safety a priority for senior leaders by spending dedicated time promoting a safety culture; • Educate staff about safety concepts such as incident reporting and a ‘fairblame’ culture; • Obtain and act upon safety issues identified by staff. We undertook 55 visits this year compared to 66 last year, and we visited over 150 different wards/departments across the five hospital sites. The reduction in visits was due to a decision to concentrate on areas providing direct clinical care to patients. Key themes identified this year were: • environmental factors; for example the physical space and fabric of the area; • equipment; • organisational/strategic issues; • manpower/staffing; • safer clinical tasks/protocol processes.

During 2014/15 we will be making further improvements to our Executive patient safety visits programme which include: • Developing a process to provide more performance data; • Strengthening the process for completion of the record sheet and involve staff ahead of the visit; • Setting timescales for the return of completed record sheets; • Utilising existing channels such as Change Registers to ensure actions identified are taken forward • Incorporating questions around the We Care programme in each visit.

7. Reducing harm events using the NHS Safety Thermometer The aim of the Safety Thermometer is to identify, through a monthly survey of all adult inpatients, the percentage of patients who receive harm free care. Four areas of harm are currently measured and most are linked to the other patient safety initiatives outlined in this report: 1. All grades of pressure ulcers whether acquired in hospital or before admission; 2. All falls whether they occurred in hospital or before admission; 3. Urinary catheter related infections; 4. Venous thromboembolism risk assessment and appropriate prevention. Our performance in delivering Harm Free Care has significantly improved from 89.14% in April 2013 to 94.87% in March 2014. This reduction in prevalence of harm has resulted from improvement work through our quality strategy and our Harm Free Care performance is now above the national average. Figure 6: NHS Safety Thermometer – % Harm Free Care EKHUFT against national performance 2013/14

Safety Thermometer Harm Free Care (%)

Harm Free Care (%)

100

95 New + Old Harms (%) EKHUFT

New Harms Only (%) EKHUFT New + Old Harms (%) National

Apr-13

Jun-13

Aug-13

Oct-13

Dec-13

Feb-14

Improvement has been seen with a reduction in prevalence of all four harms during 2013/14 but further improvement work is planned to enable us to sustain and improve further during 2014/15.

Figure 7: NHS Safety Thermometer – Prevalence individual harms EKHUFT March 2013-March 2014

Safety Thermometer Prevalence of Harm (%)

Prevalence of HArm (%)

6 Pressure Ulcers – All

Falls with Harm Catheter & UTI

New VTE

0 Mar-13

May-13

Jul-13

Sep-13

Nov-13

Jan-14

Mar-14

quality report Next steps – During 2014/15 we will: Continue to survey all adult inpatients monthly and will work to achieve a sustained reduction, linked to our CQUINs programme, in prevalence of all pressures ulcers (including patients admitted with pressure ulcers), falls with harm, urinary tract infections in patients with catheters and venous thromboembolism. We will also work with our partner organisations to identify ways of improving ‘new and old harms’. 8. Reducing infections Healthcare associated infections (HCAI) are infections resulting from clinical care or treatment in hospital, as an in-patient or out-patient, nursing homes, or even the patient’s own home. Previously known as ‘hospital acquired infection’ or ‘nosocomial infection’, the current term reflects the fact that a great deal of healthcare is now undertaken outside the hospital setting. The term HCAI covers a wide range of infections. The most well known include those caused by meticillin-resistant Staphylococcus aureus (MRSA), meticillin-sensitive Staphylococcus aureus (MSSA), Clostridium difficile (C. difficile) and Escherichia coli (E. coli). Although anyone can get a HCAI some people are more susceptible to acquiring an infection. There are many factors that contribute to this: • Illnesses, such as cancer, diabetes and heart disease, can make patients more vulnerable to infection and their immune system less able to fight it; • Medical treatments for example, chemotherapy which suppress the immune system; • Medical interventions and medical devices for example surgery, artificial ventilators, and intravenous lines provide opportunities for microorganisms to enter the body directly; • Antibiotics harm the body’s normal gut flora (“friendly” micro-organisms that live in the digestive tract and perform a number of useful functions). This can enable other micro-organisms, such as Clostridium difficile, to take hold and cause problems. This is especially a problem in older people. Long hospital stays increase the opportunities for a patient to acquire an infection. Hospitals are more “risky” places than the community outside: • The widespread use of antibiotics can lead to micro-organisms being present which are more antibiotics resistant (by selection of the resistant strains, which are left over when the antibiotics kill the sensitive ones); • Many patients are cared for together – provides an opportunity for micro-organisms to spread between them. During 2013/14 we continued to focus our efforts to reduce the number of our patients who experience two of the common HCAIs, meticillin-resistant Staphylococcus aureus (MRSA), and Clostridium difficile (C. difficile). We are measured on the number of MRSA bacteraemias (blood stream infections) which develop 48 hours following hospital admission. The Department of Health set a zero tolerance in 2013/14 for avoidable cases. Analysis of each case showed that two of the eight cases were avoidable, two were contaminants and the remaining four were unavoidable.

Preventing spread between patients by cleaning hands either with soap and water or in some cases alcohol hand gel; • Using “personal protective equipment”, where necessary, for example, disposable gloves and aprons to prevent contamination of clothing and skin; • Ensuring that, through regular cleaning, micro-organisms do not build up in the hospital environment; • Isolating patients known to be colonised with a resistant micro-organism to reduce risk of spread. Clostridium difficile We are measured on the number of C. difficile cases that have occurred 72 hours after admission to hospital. The Department of Health set us a limit of 29 or fewer cases for 2013/14; this was a very challenging limit and we struggled to meet trajectory in quarter 1. The year end total was 49; however, investigation showed that seven cases were considered to be avoidable. Figure 8: In-patient Clostridium difficile performance

Total = 96

Total = 40

Total = 49

Ap rM 10 ay -1 Ju 0 nJu 10 ly Au 10 gSe 10 p1 O 0 ct N 10 ov D 10 ec -1 Ja 0 nFe 11 bM 11 ar -1 Ap 1 rM 11 ay -1 Ju 1 n1 Ju 1 lAu 11 gSe 11 p1 O 1 ct N 11 ov D 11 ec Ja 11 nFe 12 bM 12 ar -1 Ap 2 rM 12 ay -1 Ju 2 n1 Ju 2 lAu 12 gSe 12 p1 O 2 ct N 12 ov D 12 ec -1 Ja 2 nFe 13 bM 13 ar -1 Ap 3 rM 13 ay -1 Ju 3 nJu 13 ly Au 13 gSe 13 p1 O 3 ct N 13 ov D 13 ec -1 Ja 3 nFe 14 bM 14 ar -1 4

quality report Table 7: HCAI Performance

HCAI performance 2008-09 to 2013-14 DH limit

200809

200910

201011

201112

201213

201314

201415

MRSA post 48 hour cases only

Clostridium difficile post 72 hour cases only

* Following analysis of each case, six reported MRSA bacteraemias were considered to be unavoidable.

E coli sepsis E coli is the most frequent cause of blood stream infection locally and nationally. All cases are reported to the Public Health England mandatory database each month which provides an opportunity for comparison with other trusts. The E coli rate/100,000 occupied bed days is high in East Kent (123 compared with the NHS average of 93). The reason for this high rate is unknown, but may be due to differences in population demographics. (In contrast to the high E coli rate/bed-day the E coli rate/head of population is close to, or below, the national average). More than 80% of cases of E coli bacteraemia are present at the time of admission to hospital and, therefore, in most cases represent community acquired infection. Never Event monitoring Never Events are defined as â&#x20AC;&#x2DC;serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providersâ&#x20AC;&#x2122; (NHS England 2013). The full list can be found at: http://www.england.nhs.uk/wp-content/uploads/2013/12/ nev-ev-list-1314-clar.pdf A Never Event is reported and escalated via our serious incident process. These incidents are analysed using a Root Cause Analysis (RCA) investigation to establish what went wrong and why. This enables learning to be identified and actions put in place to eliminate or reduce the likelihood of similar incidents occurring again. Learning is cascaded through the organisation at meetings and as articles in newsletters. We declared three Never Events in 2013/14; one is still being investigated. The never events and associated learning and actions from each event are detailed in the table 8:

Table 8: Never events

Never Event

Learning and actions

Misplaced nasogastric tube

As recommended by the NHS England alert, our Trust protocol has been updated to emphasise that pH testing must be used as the primary check for tube placement in the patientâ&#x20AC;&#x2122;s stomach in all cases. We use the CORTRAKÂŽ system which provides a visual tracing of the nasogastric tube placement. Since this incident occurred two staff trained in the use of CORTRAKÂŽ check the tracing to ensure the tube is placed correctly prior to commencing the feed.

Retained swab post surgery

Distractions within the theatre setting have been reduced during surgery. The swabs within the packs for this procedure are being changed to make them easier to see inside patients. Staff have been reminded about the count process and audits have been undertaken to ensure it is followed in practice.

Wrong site procedure

An appropriate and informed consent must be obtained prior to any procedure. We are updating our policy and training to include all but very minor procedures (e.g. blood tests) to have a documented consent process. All equipment packs for this needle chest aspiration now have a checklist attached to prompt staff to ensure that the correct site is selected. Figure 9: Number of never events reported

Never Events 6 5 4

2 2

3 2

1 0

1 2011/12

2 2012/13

1 1 1 2013/14

Wrong Implants or prosthesis

Misplaced nasogastic tube

Wrong site surgery/procedures

Retained foreign object post-operations

Our monitoring and analysis of never events over the last three years demonstrates a year on year reduction. We continue to improve our systems and processes to reduce the likelihood of Human Error. We are planning to raise awareness of Human Factors which contribute to incidents as part of our incident management training programme from September 2014.

quality report 10. Patient Safety Alerts NHS England produces safety alerts following analysis of incidents reported on the National Learning and Reporting System (NRLS). There have been five alerts in 2013/14. We have a cascade system within the Trust to ensure relevant specialities are aware of the alert, information is disseminated and appropriate actions taken to reduce the risks highlighted within the alert. These alerts are distributed by the national Central Alerting System (CAS). There has been some concern nationally about the number of alerts that had not been actioned by NHS Trusts, giving rise to anxiety about the safety of services. In light of this, action has been taken to review and update local processes to ensure that action is taken and progress recorded as required. 11. Reporting patient safety incidents We categorise the level of harm caused by the incident as defined in the table 9: Table 9: Level of harm

Level

Description

No harm

Impact prevented â&#x20AC;&#x201C; any patient safety incident that had the potential to cause harm but was prevented, resulting in no harm to people receiving NHS-funded care. Impact not prevented â&#x20AC;&#x201C; any patient safety incident that ran to completion but no harm occurred to people receiving NHS-funded care.

Low

Any patient safety incident that required extra observation or minor treatment and caused minimal harm, to one or more persons receiving NHS-funded care.

Moderate

Any patient safety incident that resulted in a moderate increase in treatment and which caused significant but not permanent harm, to one or more persons receiving NHS-funded care.

Severe

Any patient safety incident that appears to have resulted in permanent harm to one or more persons receiving NHS-funded care.

Death

Any patient safety incident that directly resulted in the death of one or more persons receiving NHSfunded care.

We aim to create a strong patient safety culture within the Trust; consequently we anticipate that a high number of incidents are reported whilst we try to reduce the level of harm that occurs as a result of incidents. All incidents are reported using an electronic system to make it easier for staff to report and then manage the response to incidents. In the last year we reported 12,453 clinical (patient safety) incidents. This is a 25% increase on the number reported last year; we now report around 1,000 incidents per month and our aim is to increase this further (see Figure 10). 84

Figure 10: Severity of harm

1200 1000 800 600 400 200 0

2013 04

2013 05

2013 06

2013 07

A – None (incident ran to completion but no harm occurred to the person(s) affected) B – Low (minimal harm – person(s) affected required extra observation or minor treatment).

2013 08

2013 09

2013 10

2013 11

C – Moderate (person(s) affected suffered significant but not permanent harm, requiring additional treatment)

2013 12

2014 01

2014 02

2014 03

E – Death (incident directly resulted in the death of the person(s) affected)

D – Severe (person(s) affected appears to have suffered permanent harm)

Every patient safety incident is reported to the National Reporting and Learning System (NRLS), which compares our data with similar sized Trusts every six months. The latest report shows an improvement from the reporting of 4.3 incidents per 100 bed days to 5.93 incidents per 100 bed days for the period October 2012 to March 2013. (Data for April 2013 to December 2013 has been delayed until the end of April 2014). We continue to promote and encourage staff to report incidents. We are liaising with staff on an on-going basis to improve our incident system to support both reporting and learning from incidents. Within the Trust we aim to follow the NRLS Data Quality Standards Guidance (2009). Accordingly in the last 6 months, we have introduced measures to reduce the time it takes for us to upload incidents to the NRLS; disseminated the NRLS guidance regarding the degree of harm as a result of the incident to staff; and commenced monthly checks of the provisional data supplied by the NRLS. 12. Reporting patient safety incidents Multidisciplinary patient safety grand rounds are being established in 2014/15 with the intention of having on each main site per year. These follow on from the success of the multidisciplinary grand round debates on end of life care which were held on each site last year. These will include wider team involvement and give staff an opportunity to raise any interests or concerns around specific topics including end of life pathways and care. Their aim is to try and embed learning around serious incidents that have occurred within our Trust.

quality report People feel confident we are making a difference

3. EFFECTIVE CARE – IMPROVING CLINICAL EFFECTIVENESS AND RELIABILITY OF CARE 1. Mortality reduction A mortality review shows how well the Trust is able to deliver the right patient care in the right place. Every month the specialty areas review and analyse the deaths occurring within the hospitals and identify patterns, which can highlight system failures. These reviews provide the Trust with an indicator of the safety and quality of the patient’s journey through our care. We measure our performance against the Hospital Standardised Mortality Ratio (HSMR), the Summary Hospital Mortality Index and the actual number of deaths occurring (crude mortality). We set a target of 75 for our HSMR by April 2015. Our progress can be seen in figure 11. Hospital Standard Mortality Ratio (HSMR) explained HSMR is a measurement system which compares a hospital’s actual number of deaths with their expected number of deaths. The prediction calculation takes account of factors such as the age and sex of patients, their diagnosis, whether the admission was planned or an emergency. If the Trust has a HSMR of 100, this means that the number of patients who died is exactly as predicted. If HSMR is above 100 this means that more people have died than would be expected, an HSMR below 100 means that fewer than expected died. In 2013/14, the Trust recorded an annual HSMR of 79.5, taken on 31 March 2014, which means the Trust has a 20 per cent lower mortality figure than the national average. Our HSMR measured over time is shown in the chart below; the green shows where the Trust has shown a significantly lower mortality level and blue is in the average mortality range. A red indicator shows a mortality level above the national level.

Figure 11: Hospital Standardised Mortality Ratio (HSMR) 110 105 100 95 90 85 80 75 70

2002/3

2003/4

2004/5

2005/6

2006/7

2007/8

2008/9

2009/10

2010/11

2011/12

2012/13

2013/14

The Summary Hospital Mortality Index (SHMI) is a different way of recording mortality, which takes into account patients who die within 30 days of their discharge from hospital, who are excluded from the HSMR calculation. Our performance since this new measure has been introduced is outlined in Figure 12. Figure 12: Summary Hospital Mortality Index (SHMI)

110

105

100

Q1 2011/12

Q2 2011/12

Q3 2011/12

Q4 2011/12

Q1 2012/13

Q2 2012/13

Q3 2012/13

Q4 2012/13

Q1 2013/14

Next steps • Each division within the Trust will use the information from mortality reviews and link this with their patient safety programmes, which are reviewed by the Patient Safety Board. • Each division will revise the format of their mortality and morbidity meetings to make it clear how learning from case reviews is embedded across the Trust. • The teaching “Grand Rounds” across the three sites will refocus the approach on patient safety using a facilitated case review model.

2. UK Trigger Tool explained We use the UK version of the Institute for Healthcare Improvement’s (IHI) Global Trigger Tool to provide us with an understanding of incidence of harmful events. This tool requires us to select randomly 10 sets of clinical records per site every two weeks and review them for harmful events. So far in excess of 4,270 episodes of inpatient care have been reviewed across the organisation since we started using the Tool in August 2008. It is on the data produced by this tool that we are basing our planned programme in the reduction in harmful events over the next two years. This initiative runs alongside our aim to reduce mortality and reduce harm events. We have so far, identified two key areas of priority, which are both aligned to our overall safety programme. •

Management of patients who become unwell – the Trust has invested in an electronic patient alert system, VitalPAC, which monitors all inpatients and immediately alerts staff if a patient’s condition is worsening. The

quality report •

system was implemented across the Trust during 2012, with further developments being introduced during 2013. We have concentrated our efforts in recognising patients with severe infections, specifically those patients who are being given chemotherapy for the treatment of cancer. Readmission to hospital – as part of a national award scheme, the Trust is concentrating on reducing the number of patients with long term conditions, like diabetes, who are readmitted. We are working closely with our colleagues in the community to review the support needed by patients after being discharged. We also have an internal “readmissions reduction service improvement” project. We have developed a risk stratification tool to help identify those patients who have a higher than usual risk of readmission. This tool is applied to all current inpatients and a risk score generated. We then target these patients in order to ensure the discharge planning is very clear and the risk of readmission within 30 days of discharge reduced. The tool was jointly developed with the Boston Consultancy Group and the Trust’s Information Analysts and takes into account the: • Length Of Stay • Emergency admissions • Age • Previous emergency admissions in last 12 months.

3. Enhancing Quality and Recovery Programme – Reliable Care The Trust participates in a region wide programme known as “Enhancing Quality and Recovery”. The aim of this programme is to record and report how well we perform against a set of evidence-based measures that experts have agreed all patients should receive in a number of clinical care pathways. The programme is now in its fourth year, with the aim of improving quality of care received by patients, and in 2013/14 included the following pathways: Enhancing Quality pathways: • Acute Kidney Injury (AKI) • Fractured Neck of Femur • Community acquired pneumonia • Heart failure pathway • Improved heart failure readmissions • Patient Experience • Patients on Anti-Psychotic drugs. Enhanced Recovery pathways: • Colorectal surgery • Gynaecology surgery • Hip and knee surgery • Hip and Knee surgery and heart failure patient experience. The programme requires us to audit all patient discharges from clinical pathways monthly; this is undertaken three months after the date of discharge. The reports provide information on our performance and this is benchmarked with our peer acute providers region. During 2013/14 we anticipate achieving the target compliance for all Enhancing Quality and Recovery Programme pathways. 88

Performance in 2013/14 Enhancing Quality Programme AKI – data collection

Fractured Neck of Femur data collection

Community Acquired Pneumonia

Heart Failure pathway

Heart Failure readmissions

Hip and knee replacement

Prescribing of anti psychotic drugs

Table 10: Achievement of Enhancing Quality and Recovery Programme targets

Enhanced Recovery Programme Colorectal surgery

Gynaecology surgery

Hip and Knee (H&K) surgery

H&K and HF patient experience

The performance measure is a grouping of a number of measures for each pathway. Further information on the range of measures is available on request by either emailing ekh-tr.generalenquiries@nhs.net or phoning us on 01227 766877. 4. Patient Reported Outcome Measures (PROMs) PROMs assess the quality of care delivered to patients from the patient perspective. The EQ-5D is a survey tool that seeks to assess how effective the surgery was by measuring pre- and post-operatively patients mobility, self care, usual activity, pain & discomfort, and anxiety/depression. The four procedures are: • hip replacements; • knee replacements; • groin hernia; • varicose veins. The Trust reported a lower than average EQ-5D Index Score for primary knee replacement last year. This year the number of patients who reported an improvement for this type of operation has increased, although it is still slightly below the national average. 89

quality report Table 11: PROMs data

EQ- 5D Index Score â&#x20AC;&#x201C; % Patients reporting improvement 2011

2013 provisional

2012

Procedure

Trust

National

Trust

National

Trust

National

Groin hernia

56.4

49.8

48.1

51.6

58.1

50.7

Hip replacement (primary)

88.1

87.4

88.6

89.4

84.1

90.4

Knee replacement (primary)

74.8

78.4

67.6

78.6

83.2

53.2

52.1

52.6

Varicose Vein

* Number of responses too small to be reported

The initial focus within the Trust was to ensure sufficient participation of patients for the PROMs groups to provide adequate numbers of data to make analysis meaningful. In 2013/14 the focus was on identifying a process of reporting and governance to ensure that the data received is analysed and responded to. An appropriate consultant within the Surgical Division will be the lead for each of the areas; hips, knees and groin hernia. They will have the responsibility for assessing PROMs data and actioning where appropriate. They will work closely with the Information Team who provide the PROMs data on a regular basis.

4. AN EFFECTIVE WORKPLACE CULTURE TO ENABLE QUALITY IMPROVEMENT

Improving internal communication and staff engagement

People feel cared for, safe and confident we are making a difference.

The Public Board meetings have included sessions for staff to participate in discussions around a set of themes identified from the Francis Report. A benefit of this has been to improve communication and engagement between senior management and staff. Each member of the Executive team also has an allocated open door session for any member of staff to raise concerns or find out about any aspect of the Trust’s day to day business and ideas and plans for the future. 1. Clinical Leadership Programme for frontline staff Over 50 staff participated in the Clinical Leadership Programme, in three cohorts and this programme will continue at least twice yearly. Improved Appraisal effectiveness was completed for approx 50 Medical Consultant appraisers/re-validators. In addition, Facilitating Individual Effectiveness rolling programmes, working towards leadership, are in place for 10-12 staff per site. A newly appointed Clinical Leadership programme for Medical Staff is in place. This is an integral component of the Quality Improvement and Innovation Hub (QIIH). 2. Development of a trust wide competency framework The Shared Purpose Framework guides our quality priorities along with our We Care Trust values and enables staff to connect their work to a shared vision.

• Provides and assures person-centred care, evaluating and undertaking research on patients’ experience.

Figure 13: Shared Purpose Framework competences

• Provides and assures safe care, maintains a safe environment for all, monitors and evaluates safe practice. • Provides effective care at the individual, team, service and organisational level, using evidence-based approaches and resources appropriately to achieve optimal patient outcomes. • Contributes to establishing an effective workplace culture that sustains person-centred, safe and effective care through leadership, learning, development, innovation and continuous improvement.

quality report 3. Quality Improvement and Innovation Hub – connecting us to be the best The QII Hub is a sub objective of one of the Trust’s annual objectives. Its aim is to enable and help to sustain the four shared purposes through: • Repository of Resources, Tools and E-learning, organisational and divisional projects – Shared learning together, building on what we have so we don’t reinvent the wheel and that we work together. • Work based programmes – complementing other programmes, accrediting learning in the workplace; • Mentors and Expertise – growing mentors, directory of expertise, build on learning, clinical leadership; • People and Structures – Integrated teams supporting frontline staff to the deliver shared purposes. The QII Hub aims to support all staff to bring about improvements and developments in the way they work, practice and organise services both across the Trust and the wider health economy so as to deliver on the four purposes of the Trust’s shared purpose framework and values. The QII Hub has been in development over 2013/14. There are a number of components of the QII Hub underway, including clinical leadership programmes designed to enable staff to flourish, take control and effectively influence their work-based culture and practice. This in turn enables improvements designed by the staff themselves to be developed and implemented and therefore sustained in the interest of the patients. By developing a critical mass of effective clinical leaders we are building change agents of the future who reflect our shared purposes and values. This in turn develops practice and takes forward the quality agenda. In addition the Service Improvement Team is established and works with Divisions using quality and service improvement tools to improve the quality, efficiency and productivity of patient care. One of the aims of the QII Hub is to enable staff to use these tools and techniques correctly so that staff can identify and resolve problems as quickly and as cost-effectively as possible while ensuring that any improvements in patient care are sustainable. In development are the repository and the virtual team of people to support the work of the QII Hub. A Steering Group is overseeing this work which aims to implement the QII Hub during 2014/15 and 2015/16.

Part 2 – Priorities for Improvement and Statements of assurance from the Board During 2013/14 the East Kent Hospitals University NHS Foundation Trust provided and/ or sub-contracted 100 per cent of NHS services. The East Kent Hospitals University NHS Foundation Trust has reviewed all the data available to them on the quality of care in 100 per cent of these NHS services. The income generated by the NHS services reviewed in 2013/14 represents 100 per cent of the total income generated from the provision of NHS services by the East Kent Hospitals University NHS Foundation Trust for 2013/14.

1. Clinical Audit Participation in clinical audits The Trust does not participate in every national audit, with the exception of those classified as mandatory. A formal value judgement is applied by the members of the Clinical Audit and Effectiveness Committee (CAEC) to each audit to assess the overall benefits and resources required to participate. Table 12: National confidential enquiries and national audits National audit / Enquiry

Participation

Percentage of cases included

Actions

Case Mix Programme (ICNARC CMP)

100

Has supported a business case for the expansion of ITU. Reports discussed at Critical Care Steering Group and local action plans implemented through the Surgical Governance Board.

Hip, knee and ankle replacements (National Joint Registry)

100

High revision rate identified – practice changed in particular areas.

National Audit of Seizures in Hospitals (NASH)

No current actions – awaiting local action plan

National emergency laparotomy audit (NELA)

100

No current actions – data collection is still underway. Report not expected until 2015.

Paracetamol overdose (care provided in emergency departments)

100

No current actions – awaiting audit findings

Acute care

quality report

Severe sepsis & septic shock

100

Emergency use of oxygen (British Thoracic Society)

–

Severe trauma (Trauma Audit & Research Network)

No current actions – awaiting audit findings

Patient Outcome and Death (NCEPOD) a) Lower limb amputation b) Tracheostomy care

a a) 57 b) 100

No current actions – awaiting audit findings

Blood & Transplant National Comparative Audit of Blood Transfusion – programme contains the following audits,

a) 77

a) National comparative audit for Anti-D b) National comparative audit for consent

a) National comparative audit for Anti-D – awaiting audit findings

b) 79 (QEQM) b) 58 (KCH) b) 71 (WHH)

b) National comparative audit for consent – awaiting audit findings

No Current actions – data collection still underway

Cancer Lung cancer (National Lung Cancer Audit)

Case ascertainment is not available until end of June 2014

Bowel cancer (National Bowel Cancer Audit)

No current actions – awaiting local action plan

Head & neck cancer (DAHNO)

No current actions – report due July 2014.

–

100

National oesophago-gastric cancer audit Heart Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP)

Breaches for pPCI are discussed and actions taken forward at a monthly meeting. Data collection still underway Report expected September 2014

National Vascular Register also contains the Carotid Intervention audit (CIA), which was previously listed separately in QA:

100

Congenital heart disease (Paediatric cardiac surgery) (CHD)

–

Not applicable

Adult cardiac surgery audit (ACS)

–

Not applicable

Cardiac Rhythm Management (CRM) (NHS Service information link)

No current actions – waiting audit findings. Report expected March 2015

Coronary angioplasty (NICOR Adult cardiac interventions audit)

100

No current actions – data collection still underway. Report expected September 2014

Heart failure (Heart Failure Audit)

No current actions – data collection still underway. Report expected September 2014

Cardiac arrest (National Cardiac Arrest Audit)

100

Currently used as a monitoring report rather than to inform clinical change. Resuscitation Committee will be set up shortly and this may change.

–

Paediatric Diabetes (NPDA)

100

No current actions – awaiting audit findings

Renal replacement therapy (Renal Registry)

100

No actions identified. It is intended that those areas in which the Trust is in the lowest quartile that audits may be able to be undertaken locally

Paediatric Bronchiectasis

–

Diabetes (Adult) ND (A) includes national inpatient audit (NPDIA)

100

Inflammatory bowel disease (IBD)

Pulmonary hypertension (Pulmonary Hypertension Audit)

Achieving all targets. Report discussed at Vascular audit meetings.

Not applicable

Long term conditions

Local audit to be developed National findings for this audit were due in February 2013. No current actions. Report expected September 2014

quality report

National Chronic obstructive Pulmonary Disease (COPD) Audit Programme

100

No current actions – data collection still underway

Rheumatoid and early inflammatory arthritis

–

100

No current actions.

Quarterly reports are produced and any actions are discussed at the monthly Stroke Pathway Meetings

Child Health (CHR-UK)

–

Epilepsy 12 (Childhood epilepsy audit)

100

Awaiting information from the national central team

Maternal newborn & infant clinical outcomes review programme (MBRRACEUK)

100

This is a mortality register and the deaths are reviewed as part of the on-going mortality reviews

Neonatal intensive and special care (NNAP)

Not Available

–

100

–

100

Data collection is to be undertaken over three years.

Older people Falls & fragility fracture audit programme contains the following audits, which were previously listed separately in QA: 1. Hip fracture (National Hip Fracture Database) Sentinel Stroke National Audit Programme (SSNAP) Women & Children’s Health

Paediatric asthma (British Thoracic Society) Moderate or severe asthma in children (care provided in emergency departments) PICANet (Paediatric Intensive Care

Awaiting information from the national central team – No current actions – awaiting audit findings Not applicable

Other Elective surgery (National PROMs Programme)

Note: those audits that have been greyed out are not applicable to this Trust.

No current actions – the trust is not listed in the report due to having issues with data submission.

We looked at the findings from 141 local clinical audits this year and we will take the following actions to improve the quality of healthcare provided. A full list of actions can be provided on demand but for the purposes of this report its was felt inappropriate to list all the actions as the number is considerable, therefore, a sample of actions identified through the clinical audit programme are listed below where the audit was at a stage to identify actions: Table 13: Actions identified following local audits Audit

Action

Liver core biopsy

Disseminate and discuss audit findings with radiology and gastroenterology consultants Improve suboptimal biopsy rate in chronic viral or autoimmune hepatitis. Radiologists to commit to taking at least 20 mm core length Address the reasons for and monitor recent reduction of combined core length. Give individual feedback to radiologists on samples where appropriate Carry out a re-audit

Imaging of adult patients with head injuries (re-audit)

No action plan or re-audit required according to the project lead.

Hypoglycaemia management in neonates

All babies with diagnosed hypoglycaemia have their own case notes Hypoglycaemic babies to be identified in a book kept on each ward Importance of pre-feed BM's was discussed with ward managers

Basal cell carcinoma

Awareness of audit findings and guidelines were disseminated amongst team

Antenatal tests

Share audit findings with Group Practice Leads (GPLs) Ensure doctors aware of need to record weekly SFH from 28 weeks

Home haemodialysis

Increase staff awareness via a master class including relevant information in the HHD patient information leaflet Topic to be considered for re-audit to see if timing of referrals are recorded, the number of patients independent with access management from HD units, length of time on HD, exploring barriers that impact duration and assess any unique influences affecting the patients

quality report

Audit

Action

Assessment and management of thromboembolism (DVT & PE)

Pathways to be updated to include inpatient management & to be made available on PAS Ensure pathways from ambulatory care are filed in the hospital notes. Patient notes to be ordered once patient enters care pathway Nurses completing the assessment have been educated to ensure documentation is completed for:1. Risk factors & Wells or Probability score 2. Warfarin doses to be documented 3. Reasons why a follow up was not arranged in medical outpatients 4. Any deviation from the policy Nurses completing the assessment have been educated to ensure all appropriate blood tests are ordered

Transfer between hospitals

The SBAR transfer form revised so that all information required when transferring patients between hospital sites can be documented. Re-audit when revised SBAR transfer form implemented to ensure that it is in use & fit for purpose

Inadvertent peri-operative hypothermia

Reiterate the importance of fluid warming to all staff and use heating cabinets in theatre

Quality measure implementation for prevention & treatment of surgical site infection

Raise awareness with current staff of the findings of the audit Development of information leaflet for patients Information and awareness among surgical department about quality measures to prevent SSI Utilisation of Nurse Practitioner in SSI surveillance either by phone interview or OPD Raise awareness with anaesthetic colleagues and theatre staff for better control of hypothermia and hypotension during intra-operative phase Second dose of antibiotics in operations lasting longer than 4 hours SSI quality measures discussion with surgical ward sisters

Audit

Action

Goal setting with service users & carers at Buckland Day Hospital

Increase in the number of patients whose goals set by the MDT are set in collaboration with them Increase in the number of patients whose goals are discussed and agreed with them Increase in the involvement of carers in the goal-setting process Ensure that all goals set are SMART (specific, measureable, achievable, realistic and time limited) Ensure that goals are reviewed regularly through the course of the therapy Increase in outcome measures used to evaluate therapeutic intervention effectively Increase in outcome measures used to evaluate therapeutic intervention effectively Re-audit of goal setting when appropriate

Management of severe hyponatraemia

Improve awareness of the Trust guideline on the management of electrolyte disturbance Clinical chemistry department should notify the endocrinology team as well as the clinical team in charge, whenever there is a result of serum sodium =/< 120 mmol/l Make appropriate adjustment to reduce the time needed to measure serum/ urine osmolality Update/clarify definition of acute and chronic hyponatraemia in the Trust guideline on management of electrolyte disturbance Carry out a re-audit

quality report 2. Participation in clinical research The number of patients receiving NHS services provided or sub¬ contracted by the East Kent Hospitals University NHS Foundation Trust in 2013/14 that were recruited during that period to participate in research approved by a research ethics committee was 1,510, compared to 960 in 2012/13. Whilst this is an improvement over the recruitment last year, this was still slightly below the target of 1,562. The target for recruitment into portfolio trials is 1,900 for 2014/15. A key overriding Government goal for the NHS is for every willing patient to be a research participant, enabling him or her to access novel treatments earlier. The formation of Academic Health Sciences Networks (AHSNs) has supported the Academic Health Science Centres to build on their models of accelerating adoption and diffusion, and will present a unique opportunity to align education, clinical research, informatics, innovation, and healthcare delivery. East Kent Hospitals University NHS Foundation Trust remains committed to improving the quality of care we offer and to making our contribution to wider health improvement. The Trust wishes to provide better care to patients and the local population by bringing sustainable transformational change to health research, development and innovation in East Kent. Our Research, Development and Innovation Strategy focuses on: • Fostering a vibrant research, development and inquiry culture in practice; • Growing our staff’s capability and capacity across a broad range of approaches, methodologies and methods to enable all the factors that influence patient outcomes and experiences to be embraced locally; • Growing our own research so that EKHUFT researchers substantially increase research and innovation outputs and impacts; • Supporting the research endeavours led by others through increased recruitment to NIHR portfolio-adopted and commercially funded studies.

3. Information on the use of the CQUIN Framework A proportion of East Kent Hospitals University NHS Foundation Trust’s income in 2013/14 was conditional upon achieving quality improvement and innovation goals agreed between East Kent Hospitals University NHS Foundation Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework (CQUIN). The monetary total for income in 2013/14 conditional upon achieving quality improvement and innovation goals was £10,621,245 including £1,265,725 related to Specialised Services provided. This was 2.5 per cent of the contract values. The monetary total for the associated payments in 2012/13 was £10,336,822. Details of the 2013/14 CQUIN programme are listed below in Table 14:

100

Table 14: CQUIN performance CQUIN SCHEDULE 2013/14 General Services Schemes High Impact Innovation

% value

*£000s (est.)

Origin

Pre-Qualification criteria

NATIONAL

Friends & Family Test – Implement and achieve required response rates

0.25

935

NATIONAL

Safety Thermometer – maintain monthly surveys and achieve required reduction in pressure ulcers

0.25

935

NATIONAL

Improving diagnosis of dementia – Improve case finding, assessment and referral, improve training and ensure support for carers

0.25

935

NATIONAL

Reduction in incidence of VTE – Maintain improvements in risk assessment and investigate causes of hospital acquired VTEs

0.25

935

NATIONAL

Enhancing Quality & Recovery – Achieve improvements in provision of high quality care through the EQRP pathways

0.5

1,870

LOCAL

Chronic Obstructive Pulmonary Disease – Ensure referral to smoking cessation and pulmonary rehabilitation

0.25

935

LOCAL

Stroke – Earlier thrombolysis, brain imaging and care in a stroke unit and measure the impact on quality of life

0.25

935

LOCAL

Maternity – Improve referral to smoking cessation services and increase breastfeeding rates

0.25

935

LOCAL

Hips & Knees – Conduct audit to Identify the causes of post operative complications to enable improvement

0.25

935

LOCAL

2.50%

£9.35m

Total Value

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Table 14: CQUIN performance (continued) CQUIN SCHEDULE 2013/14 Specialised Services Schemes

% value

*£000s (est.)

Origin

Friends & Family Test – Implement and achieve required response rates

0.25

127

NATIONAL

Safety Thermometer – maintain monthly surveys and achieve required reduction in pressure ulcers

0.25

127

NATIONAL

Improving diagnosis of dementia – Improve case finding, assessment and referral, improve training and ensure support for carers

0.25

127

NATIONAL

Reduction in incidence of VTE – Maintain improvements in risk assessment and investigate causes of hospital acquired VTEs

0.25

127

NATIONAL

Quality Dashboard – submission of data

0.25

127

LOCAL

Support Operational Delivery Networks (ODNs)*

0.1

50.8

LOCAL

Renal – Acute Kidney Injury data collection

0.23

117

LOCAL

Cardiac Inpatient Pathway – Audit

0.23

117

LOCAL

Cancer Nurse Specialist Services – patient feedback

0.23

117

LOCAL

Haemophilia patients – Joint score assessments

0.23

117

LOCAL

Neo natal – delivery of Total Parenteral Nutrition (TPN)

0.23

117

LOCAL

2.50%

£1.27m

Total Value * Support for the ODNs was a mandatory payment and was therefore not rated.

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Eight of the nine General Services schemes were achieved in full. One of the four measures related to the Stroke Pathway was not achieved; increasing the number of patients admitted to a stroke unit within four hours of admission to 85 per cent by quarter four. Targets for all of the schemes related to the provision of Specialised Services were achieved. The value of the 2014/15 CQUIN programme is estimated to be worth just over £10 million pounds and a summary of these measures can be found under Priority 5 of the Annual Quality Objectives for 2014/15 section of this report. Further details of the agreed goals for 2014/15 and for the following 12 month period are available on request by contacting: East Kent Hospitals University NHS Foundation Trust Headquarters Kent and Canterbury Hospital Ethelbert Road Canterbury Kent CT1 3NG e-mail: ekh-tr.generalenquiries@nhs.net Phone: 01227 766877 Fax: 01227 868662 4. Information relating to registration with the Care Quality Commission (CQC) and periodic / special reviews East Kent Hospitals University NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is “Registered without Conditions”. The Care Quality Commission has not taken enforcement action against East Kent Hospitals University NHS Foundation Trust during 2013/14. East Kent Hospitals University NHS Foundation Trust participated in a Care Quality Commission Inspection relating to the following areas during 2013/ 2014 as part of the Wave 2 inspection programme: • A&E • Medical Care (including older people’s care) • Surgery • Critical care • Maternity and family planning • Services for children and young people • End of life care • Outpatients. The Trust is not yet in receipt of the draft or final inspection report and will respond to the findings of the March 2014 CQC Inspection once the report is available and will monitor improvements against any action plan required.

103

quality report 5. Data quality – NHS Number and General Medical Practice Code Validity The East Kent Hospitals University NHS Foundation Trust submitted records during 2013/14 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data which included the patient’s valid NHS number was: Table 15: NHS Number and General Medical Practice Code Validity

Category

2011/12 (%)

2012/13 (%)

2013/14 (%)

% for admitted care

99.5

99.89

99.8

% for outpatient care

99.8

99.99

99.9

% for A&E care

98.0

99.43

98.9

% for admitted care

100

99.99

100

% for outpatient care

100

99.99

100

% for A&E care

99.9

100

NHS Number

General Medical Practice Code

6. Information Governance Toolkit attainment levels The East Kent Hospitals University NHS Foundation Trust score for 2013/14 for Information Quality and Records Management, assessed using the Information Governance Toolkit, was 72 per cent and was graded green. The East Kent Hospitals University NHS Foundation Trust will be taking the following actions to improve data quality: • The Trust will undertake a Trust wide audit of corporate records to assess compliance in quarter 3 2014/15; • Specific risk management training for Information Asset Owners will be provided this year.

104

7. Clinical coding East Kent Hospitals University Foundation Trust was not subject to the Payment by Results clinical coding audit during 2013/14 by the Audit Commission. 8. Friends & Family Test We introduced the Friends and Family Test in April 2013 for inpatients and A&E attendees. The Friends and Family Test asks the patient how likely they are to recommend the ward or A&E department to their friends or family. The scoring ranges from: • Extremely likely; • Likely; • Neither likely nor unlikely; • Unlikely; • Extremely unlikely. There is also a “don’t know” option which isn’t scored, and an opportunity to write further comments. Nationally, Trusts are measured using the Net Promoter Score (NPS) where a score of approximately 50 is deemed good. In October 2013 we introduced the Maternity Friends and Family Test successfully. Initially response rates were low, but they have steadily increased over the year and as a Trust we are now achieving the 15% response rate. Our Trust NPS is around 73 within the inpatient areas, with maternity scoring around 75 in the March 2014 data. The NPS for A&E is consistently lower than the other two areas and is subject to a detailed action plan to improve performance in the area. All comments are analysed and summarised as feedback to patients and visitors, with corresponding action plans that respond to the feedback are in place in each ward and department. For 2013/14, NHS England has written to all NHS providers asking them to consider reporting on the patient element of the Friends and Family Test (FFT) within the quality accounts (gateway reference 00931). Although this is not a statutory requirement, the patient element of the FFT has been included in the table of indicators below.

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Table 16: Prescribed Quality Indicators 2013-14 Indicator

Trust

Reason for performance

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre (Jul 12 – June 13) with regard to –

(a) 0.9673, Banding 2 – Trust’s mortality rate is as expected

(a) the value and banding of the summary hospital-level mortality indicator (“SHMI”) for the trust for the reporting period; and

(b)Jul 12 – Jun 13 13.8%

The performance is currently lower than the national average for both indicators. Regular reporting of Z51.5 coding is already scrutinised by the Patient Safety Board (PSB) with the aim to reduce this coding rate still further.

(b) the percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the trust for the reporting period.

Apr 12 – Mar 13 12.7%

The trust’s patient reported outcome measures scores for – (i) groin hernia surgery, (ii) varicose vein surgery, (iii) hip replacement surgery, and (iv) knee replacement surgery, during the reporting period. (EQ-5D index case mix adjusted health gain) (This is explained in more detail within the body of the report)

Apr 13 – Sept 13 (i) 0.093 (ii) N/A (iii) 0.463 (iv) 0.351

Apr 12 – Mar 13 (i) 0.092 (ii) N/A (iii) 0.437 (iv) 0.30

106

The Trust has improved the performance in patient outcomes for primary knee replacement for the latest data set.

Actions to be taken

National Average

Trusts and FTs with lowest score

Trusts and FTs with highest score

1. Real time reporting via balanced score card to divisions and as part of the regular Information report to the PSB

(a) not published

(a) The Wittington Hospital NHS Trust (0.6259)

a) Blackpool Teaching Hospitals (1.1563)

2. Review of data and collaboration with commissioners to identify out of hospital deaths

(b)Jul 12 – Jun 13 20.65%

(b)Jul 12 – Jun 13 Taunton and Somerset NHS FT (0%)

(b)Jul 12 – Jun 13 East & North Hertfordshire NHS FT (44.1%)

3. Review of end of life care beds and planning following patient discharge

Apr 12 – Mar 13 20.4%

Apr 12 – Mar 13 Taunton & Somerset NHS FT (0.1%)

Apr 12 – Mar 13 East & North Hertfordshire NHS FT (44.0%)

1. Identified clinical lead for all PROMs within Division.

Apr 13 – Sept 13 (i) 0.086 (ii) 0.102 (iii) 0.447 (iv) 0.339

Apr 13 – Sept 13 (i) The Dudley Group (0.019) (ii) City Hospitals Sunderland (0.058) (iii) Hinchingbrooke Healthcare Trust (0.373) (iv) Brighton and Sussex University Hospitals (02.64)

Apr 13 – Sept 13 (i) Derby Hospitals (0.138) (ii) Newcastle upon Tyne Hospital (0.094) (0.167) (iii) Spire Norwich Hospital (0.545) (iv) Wirral University Teaching Hospital (0.429)

Apr 12 – Mar 13 (i) 0.085 (ii) 0.093 (iii) 0.438

Apr 12 – Mar 13 (i) Boston West Hospital (0.015) (ii) King’s College Hospital (0.023) (iii) The Wittington Hospital (0.319) (iv) West Middlesex University Trust (0.195)

2. Review patient feedback.

Apr 12 – Mar 13 (i) BMI – The Foscote Hospital (0.157) (ii) Doncaster and Bassetlaw (0.175) (iii) Oakes Hospital (0.543) (iv) Spire Fylde Coast Hospital (0.409)

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quality report

Table 16: Prescribed Quality Indicators 2013-14 Indicator

Trust

Reason for performance

The percentage of patients aged – (i) 0 to 15; and (ii) 16 or over, readmitted to a hospital which forms part of the trust within 28 days of being discharged from a hospital which forms part of the trust during the reporting period. (Other large acute Trusts comparative dataset)

2010/11 (i) 7.77%

The Trust has recognised that our readmission rate for adults, although below the national average, is higher than our local peer group. We have been working internally to understand the reasons for this finding. This has been found to be due, in part, to the anxiety of residential and nursing home staff to continue care following discharge from the acute setting.

(ii) 12.11%

2011/12 (i) 10.05%

(ii) 12.53%

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the trust’s responsiveness to the personal needs of its patients during the reporting period. Overall patient experience score only** Direct comparison with previous years’ composite score is not possible due to a change in the questions in the inpatient survey for 2013.

2013/14 (77)

**The criteria for 2013/14 have changed to include the overall patient experience score, rather than a subset of personal needs. This makes comparison with previous years’ performance difficult to quantify. Performance is around the national average.

The percentage of staff employed by, or under contract to, the trust during the reporting period who would recommend the trust as a provider of care to their family or friends.

2012 61%

We have sought staff feedback as part of the “We Care” programme in order to understand the reasons why our performance has deteriorated in the last survey results. The Trust is in the lower quartile of performance this year. The staff survey results for 2013 are included within the Annual Report and Accounts

2013 56.8%

108

Actions to be taken

National Average

Trusts and FTs with lowest score

Trusts and FTs with highest score

1. Currently testing a predicative readmission scoring model to target patients who are frequently readmitted due to their longterm condition, dependency problems and frailty.

2010/11 (i) 10.15%

(i) Epsom & St Helier University Hospitals NHS Trust (6.49%)

(i) The Royal Wolverhampton Hospitals NHS Trust (14.34%)

(ii) 11.42%

(ii) Northern Lincolnshire and Goole NHS FT (9.18%)

(ii) Heart of England NHS FT (14.09%)

2011/12 (i) 11.71%

(i) Shrewsbury and Telford NHS Trust (6.73%)

(i) Blackpool, Fylde and Wyre NHS FT (16.89%)

(ii) 11.45%

(ii) Norfolk and Norwich University NHS Foundation Trust (9.34%)

(ii) Epsom & St Helier University Hospitals NHS Trust (13.8%)

1. The “We Care” programme is currently in progress, with a series of actions identified to improve patient experience and responsiveness to individual patient needs. This is further outlined in the patient experience section of this report

2013/14 (76.9)

2013/14 Mayday Hospital (67.1)

2013/14 Royal Marsden Hospital (87)

1. The “We Care” programme is currently in its second year of roll-out, with a series of actions identified to improve in this area.

2012 (55%)

2012 North Cumbria Hospitals (36%)

2012 Newcastle Upon Tyne Hospitals (86%)

2013 (66.2%)

2013 Mid Yorkshire Hospitals (39.6%)

2013 Papworth Hospital (93.9%)

2. Undertaking a national service improvement project with a local CCG to understand better the reasons for readmissions.

2. There are actions identified by the Board of Directors following the results the staff survey in 2013

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quality report

Table 16: Prescribed Quality Indicators 2013-14 Indicator

Trust

Reason for performance

The percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period.

Q3 2013/14 96.3%

Our performance over time has shown continual improvement and we have met the CQUIN target for this year set at 95%. The year end position for the Trust was 97%.

Jan â&#x20AC;&#x201C; 14 96%

The rate per 100,000 bed days of cases of C.difficile infection reported within the trust amongst patients aged 2 or over during the reporting period.

2011-12 11.4

2012-13 12.2

110

The Trust has an active programme of infection prevention and control and the incidence of C. difficile infections has decreased significantly over time. Performance is reported to the Board monthly as part of the Clinical Quality and Patient Safety Report. Further details can be found in figure 5 and Table 5 of this report.

Actions to be taken

National Average

Trusts and FTs with lowest score

Trusts and FTs with highest score

VTE risk assessment tool onto VitalPAC, which means this can be completed more easily by staff in order to achieve 100% compliance.

Q3 2013/14 95.9%

Q3 2013/14 North Cumbria University Hospitals (77.7%)

Q3 2013/14 South Essex Partnership, Royal National Hospital for Rheumatic Diseases, Queen Victoria Hospital and Bridgewater Community Trust (100%)

Jan – 14 96%

Jan – 14 North Cumbria University Hospitals (75.12%)

Jan – 14 9 Trusts (100%)

2011-12 21.8

2011-12 Tameside Hospital (51.6)

2011-12 Birmingham Women’s, Moorfields Eye, and Queen Victoria (0)

2012-13 17.3

2012-13 North Tees and Hartlepool (30.8)

2012-13 Birmingham Women’s, Moorfields Eye, Queen Victoria, Liverpool Women’s, Alder Hey (0)

1. An educational campaign will emphasise need to detect all C. difficile cases in patients admitted with diarrhoea, to avoid late detection resulting in pre72hr cases becoming post72hr cases. 2. There will be closer monitoring of antimicrobial prescribing in the Surgical Division and further liaison between the Infection Prevention and Control Team and Surgical Services on their responsibilities for internal control on antimicrobial usage.

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quality report

Table 16: Prescribed Quality Indicators 2013-14 Indicator

Trust

Reason for performance

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the response rates of the Friends and Family Test in the inpatient, A&E and maternity areas.

Inpatient Feb-2014 32.8%

The Trust was slightly below the national performance requirements until recently for A&E.

A&E Feb-2014 13.6% Maternity Feb-14 Antenatal – (10.3%) Birth – (26.8%) Post Natal – (28.3%) Community – (5.5%)

Inpatient Mar-2014 32.59% A&E Mar-2014 16%

Maternity Mar-14 Antenatal – (7.5%) Birth – (26.1%) Post Natal – (25.8%) Community – (7.1%)

112

Actions to be taken

National Average

Trusts and FTs with lowest score

Trusts and FTs with highest score

We implemented texting and interactive voice messaging service to supplement the existing hard copy feedback card system that has enabled us to achieve the 15% standard for A&E for last months performance figures

Inpatient Feb-2014 34%

Inpatient Feb-2014 Maidstone and Tunbridge Wells 16.19%

Inpatient Feb-2014 Hinchingbrooke Hospital 78.88%

A&E Feb–2014 18.6%

A&E Feb–2014 Great Western Hospitals 1.5%

A&E Feb–2014 Bedford Hospital 66.1%

Maternity Feb-14 Antenatal – (15.5%) Birth – (22.1%) Post Natal – (26%) Community – (13.4%)

Maternity Feb-14 Antenatal – Four Trusts with (0%) Birth – Northern Devon HC Trust (0%) Post Natal – Northern Devon HC Trust (2.1%) Community – Sheffield Teaching FT – (0.2%)

Maternity Feb-14 Antenatal – East Cheshire NHS Trust (74.3%) Birth – West Suffolk NHS FT (64.1%) Post Natal – Salisbury NHS FT (66.7%) Community – Imperial College HC Trust (67.2%

Inpatient Mar-2014 34.8%

Inpatient Mar-2014 Heart of England NHS FT 10.86%

Inpatient Mar-2014 Queen Victoria NHS FT 84.97%

A&E Mar-2014 Milton Keynes NHS FT & West Hertfordshire NHS Trust 1.6%

A&E Mar-2014 North Cumbria Hospitals Trust 53.5%

Maternity Mar-14 Antenatal – King’s College NHS FT (0.1%) Birth – St Georges Healthcare NHS Trust (1.3%) Postnatal – Bolton NHS FT (1.18%) Community – Four Trusts with (0%)

Maternity Mar-14 Antenatal – University Hospitals of Morecambe Bay FT (73%), Four Trusts with (0%) – The Princess Alexandra NHS Trust & East & North Hertfordshire NHS Trust (65.5%) Post natal – Bedford Hospital NHS Trust 90.0%) Community – Medway NHS FT (67.62%)

A&E Mar-2014 18.5%

Maternity Mar-14 Antenatal – (14.6%) Birth – (22.6%) Post Natal – (25.8%) Community – (13.12%)

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Table 16: Prescribed Quality Indicators 2013-14 Indicator

Trust

Reason for performance

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the NPS scores of the Friends and Family Test in the inpatient, A&E and maternity areas.

Inpatient Feb-2014 73

The Trust performs above the national benchmarked figures in all areas other than in A&E. Feedback from patients suggests this is due to perceived long waiting times,lack of faciltiies to obtain drinks, the attitudes expressed by some members of the clinical team and the adequate and timely management of pain.

A&E Feb–2014 33

Maternity Feb -14 Antenatal – 87 Birth – 80 Post Natal – 81 Community – 90

114

Actions to be taken

National Average

Trusts and FTs with lowest score

Trusts and FTs with highest score

Matrons in A&E are introducing comfort rounds to ensure that every patient is reviewed every couple of hours. This includes information on their pain management, food and drink availability and any restrictions, ensuring that call bells are within reach and to ascertain if there are any outstanding needs.

Inpatient Feb-2014 72

Inpatient Feb-2014 Medway NHS FT 18

npatient Feb-2014 Royal National Hospital for Rheumatic Diseases 94

A&E Feb–2014 55

A&E Feb–2014 Medway NHS FT -5

A&E Feb–2014 The Wirral University Hospital and Dartford Hospital 90

Maternity Feb-14 Antenatal – 67 Birth – 75 Post Natal – 64 Community – 75

Maternity Feb-14 Antenatal – Sheffield Teaching Hospitals, Birmingham Women’s & North Middlesex Trusts (0) Birth – Chelsea & Westminster NHS FT (-9) Post Natal – North Middlesex University NHS Trust (20) Community – Southend University FT – (-100)

Maternity Feb-14 Antenatal – Nine Trusts with (100) Birth – Seven Trusts with (100) Post Natal – Northern Devon HC Trust (100) Community – 10 Trusts with (100)

Matrons are participating in these comfort rounds when on duty. Pain assessments are being checked to ensure they follow the current Trust guidelines. The William Harvey A&E site is undertaking a trial to assess whether placing a HCA in the waiting area to check patients are safe, comfortable and informed improves care and feedback.

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Table 16: Prescribed Quality Indicators 2013-14 Indicator

Trust

Inpatient Mar-2014 72

Reason for performance

A&E Mar–2014 26

Maternity Mar -14 Antenatal – 82 Birth – 81 Post Natal – 69 Community – 86

The number and, where available, rate of patient safety incidents reported within the trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death. (Large Acute Category) (This is explained in more detail within the body of the report)

Oct 2012 – March 2013 Severe = 0.8% (n=40)

Death = 0.2% (n=10)

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In the past we have relied on the individual reporters and their managers to assign the level of harm to each incident reported. This has resulted in variation of the assessment of patient harm at both severe harm and death categories. Recently, we have taken a decision to record all deaths following elective surgery to ensure these are all investigated using a formal RCA process; this may have contributed to the increase of these death related incidents in the most recent report published.

Actions to be taken

1. The central team will review the final attribution of harm to all severe harm and death incidents to ensure this is consistent and accurate before the data extraction to the NRLS

National Average

Trusts and FTs with lowest score

Trusts and FTs with highest score

Inpatient Mar-2014 72

Inpatient Mar-2014 Medway NHS FT 28

Inpatient Mar-2014 Liverpool Heart & Chest Hospital NHS FT (96)

A&E Mar–2014 54

A&E Mar–2014 Medway NHS FT (1)

A&E Mar–2014 The Wirral University Hospital (90)

Maternity Mar -14 Antenatal – 67 Birth – 77 Post Natal – 64 Community – 74

Maternity Mar -14 Antenatal – Mid Essex Hospital Services Trust & West Middlesex University NHS Trust (0) Birth – Chelsea & Westminster NHS FT (12) Post Natal – Bart’s Health NHS Trust (10) Community – Heatherwood & Wexham Park NHS FT & Isle of Wight NHS Trust (-100)

Maternity Mar -14 Antenatal – Six Trusts with 100 Birth – Mid-Cheshire NHS FT & St Georges Healthcare NHS Trust (100) Post Natal – South Tyneside NHS FT & The Royal Bournemouth and Christchurch NHS FT (100) Community – 20 Trusts with (100)

Oct 2012 – March 2013

Severe = 0.6% (n=973)

Doncaster and Bassetlaw Hospitals Severe = 3.4% (n=59)

East Lancashire Hospitals Severe =0% (n=0)

Death = 0.2% (n=267)

City Hospitals Sunderland, North West London Hospitals & Shrewsbury and Telford Hospital

Barking, Havering and Redbridge, Pennine Acute Hospitals & East Lancashire Hospitals

Death = 0.4% (n=20, 8 & 15 respectively)

Death = 0% (n=0)

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Table 16: Prescribed Quality Indicators 2013-14 Indicator

Trust

Reason for performance

Apr-13 to Sept â&#x20AC;&#x201C; 13

Severe = 0.3% (n=14)

Death = 0.2% (n=11)

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Recently, we have taken a decision to record all deaths following elective surgery to ensure these are all investigated using a formal RCA process; this may have contributed to the increase of these death related incidents in the most recent report published.

Actions to be taken

National Average

Trusts and FTs with lowest score

Trusts and FTs with highest score

1. The central team will review the final attribution of harm to all severe harm and death incidents to ensure this is consistent and accurate before the data extraction to the NRLS

Apr-13 to Sept – 13

Severe = 0.5% (n=899)

Calderdale & Huddersfield NHS FT Severe = 2.6% (n=86)

East Lancashire Hospitals Severe = 0% (n=1)

Death = 0.1% (n=191)

University Hospital of North Staffordshire NHS FT & East Lancashire Hospitals NHS Trust Severe = 0% (n=1)

Barking, Havering and Redbridge Hospitals NHS Trust & Doncaster & Bassetlaw NHS FT Death = 0% (n=0)

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quality report Part 3 – Other Information How we keep everyone informed Measuring our Performance Foundation Trust members are invited to take part in meetings at which quality improvement is a key element of the agenda. We encourage feedback from Members, Governors and the Public. The Patient and public experience team’s raises awareness of programmes to the public through hospital open days and other events. Quality is discussed as part of the meeting of the Board of Directors and our data is made publically available on our website.

The Trust has numerous other patient, carer, family and staff groups, which meet regularly in disparate divisions and departments.

The trust amalgamated the roles of Equality and Human Rights Manager and Head of Public and Patient Engagement at the beginning of the year to ensure that Trust engagement included those sections of the community who are often not included in engagement activity. The new Head of Equality and Engagement is currently reviewing The Trust’s Patient and Public Engagement strategy. The coming year will see enhanced patient involvement resulting in improved patient experience and outcomes. During the last year, the trust has held two engagement events for members of Voluntary Community Organisations (VCOs) when the Trust’s annual plan, equality performance and patient nutrition were discussed. In addition, the Patient and Public Advisory Forum met on four occasions and explored a large range of quality issues. The Trust has numerous other patient, carer, family and staff groups, which meet regularly in disparate divisions and departments. The following table outlines the performance of the East Kent Hospitals University NHS Foundation Trust against the indicators to monitor performance with the stated priorities. These metrics represent core elements of the corporate dashboard and annual patient safety programme presented to the Board of Directors on a monthly basis.

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Table 17: Measures to monitor our performance with priorities Data Source

Actual 2009/2010

Actual 2010/2011

Actual 2011/2012

Actual 2012/2013

Actual 2013/14

Limit/Target 2013/14

C difficile – reduction of infections in patients > 2 years, post 72 hours from admission

Locally collected and nationally benchmarked

MRSA bacteraemia – new identified MRSA bacteraemias post 48 hours of admission

Locally collected and nationally benchmarked

In-patient slip, trip or fall, includes falls resulting in injury and those where no injury was sustained

Local incident reporting system

2,560

2,340

Pressure ulcers – hospital acquired pressures sores (grades 2-4, avoidable and unavoidable)

Local incident reporting system

274

Patient safety

(1 avoidable 3 unavoidable)

(2 avoidable, 4 unavoidable, 2 contaminants)

2,107

2,009

2,156

See report

233

236

303

335

See report

Patient Outcome/clinical effectiveness Hospital Standardised Mortality Ratio (HSMR) – overall

Locally collected and nationally benchmarked

78.8

84.2

78.8

79.5

75 by 2015

Crude Mortality (elective %)

Locally collected

0.766

0.616

0.489

0.3

Crude Mortality (non elective %)

Locally collected

35.14

33.09

30.95

30.7

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Table 17: Measures to monitor our performance with priorities Data Source

Actual 2009/2010

Actual 2010/2011

Actual 2011/2012

Actual 2012/2013

Actual 2013/14

Limit/Target 2013/14

Patient Outcome/clinical effectiveness Summary Hospital Mortality Index (%)

Locally collected and nationally benchmarked

3.95%

3.90%

3.17% (Q2 2012/13 data)

Enhancing Quality – Community Acquired Pneumonia

Locally collected and regionally benchmarked

71.04

81.16

80.17

58.46 Month 11

58.66

Enhancing Quality – Heart Failure

Locally collected and regionally benchmarked

26.72

51.99

66.9

73.68 Month 11

52.80

Enhancing Quality – Hips & Knees

Locally collected and regionally benchmarked

94.48

95.74

98.58

92.61 Month 11

38.28

Patient experience The ratio of compliments to the total number of complaints received by the Trust (compliment : complaint)

Local complaints reporting system

8:1

15:1

27:1

20:1

12:1

Patient experience – composite of five survey questions from national inpatient survey

Nationally collected as part of the annual in-patient survey

65.3%

66.1%

65.6%

65.8%

No longer reported

See indicator below

Overall patient experience score

Nationally collected as part of the annual in-patient survey

N/A

77%

> national average

Single sex – mixing for clinical need or patient choice only

Locally collected

100%

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All data classified as nationally collected are governed by standard national definitions. All data collected locally are reported via nationally recognised incident and complaints management systems, or internal reports generated from the Patient Administration System (PAS). The metrics developed around clinical effectiveness were limited to one indicator, the overall HSMR in the 2008/09 Annual Report. This section has been further developed to cover six indicators in order to triangulate mortality data using the Summary Hospital Mortality Index. The metrics included in the patient experience section have developed since the publication of the 2008/09 Annual Report. These are now aligned to the measures agreed by the Board of Directors to monitor the strategic objective for providing an excellent patient experience. Changes to some of the performance figures published in the last quality report occurred this year. The HSMR figures were re-calculated by Dr Foster as part of their annual programme, although these were correct at the time of publication. Some patient falls and pressure ulcer data were reclassified following detailed investigation affecting the published data in the 2012/13 report. The Department of Health made changes to the proposed indicators for reporting for inclusion in the 2012/13 Quality Report. Consequently, there will be changes to the metrics adopted by the Trust to account for these proposals. Table 18: Performance with National Targets and Regulatory Requirements 20082009

20092010

20102011

20112012

20122013

20132014

National target achieved

Clostridium difficile year on year reduction

MRSA â&#x20AC;&#x201C; maintaining the annual number of MRSA bloodstream infections at less than half the 2003/04 level

Cancer: two week wait from referral to date first seen: all cancers

98.8%

94.95%

95.30%

96.6%

95.43%

94.8%

Cancer: two week wait from referral to date first seen: symptomatic breast patients

93.99%

95.13%

93.93%

92.7%

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Table 18: Performance with National Targets and Regulatory Requirements 20082009

20092010

20102011

20112012

20122013

20132014

National target achieved

All cancers: 31 day wait from diagnosis to first treatment

99.13%

99.06%

99.11%

98.2%

All Cancers: 31day wait for second or subsequent treatment or surgery

96.0%

97.31%

99.04%

97.64%

97.48%

13/14 monitor RAF guidance requires the cancer 31 day wait to be split by Rx type

- Surgery

Not previously reported separately

97.6%

- Anti-cancer drug treatment

Not previously reported separately

99.6%

- Radiotherapy All Cancers: 62-day wait for first treatment, from urgent GP referral to treatment

Not applicable to this Trust 99.3%

71.98%

87.67%

88.98%

87.83%

86.6%

95.22%

98.53%

97.20%

87.8%

Maximum time of 18 weeks from point of referral to treatment – non admitted

91.71%

98.34%

97.07%

96.36%

97.16%

98.2%

Maximum time of 18 weeks from point of referral to treatment – admitted

86.71%

89.97%

89.39%

91.80%

91.96%

90.7%

Maximum time of 18 weeks from point of referral to treatment – incomplete pathway

67.86%

92.04%

94.14%

95.21%

94.73%

95.4%

All Cancers: 62-day wait for first treatment, from consultant screening service referral

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20082009

20092010

20102011

20112012

20122013

20132014

National target achieved

Maximum waiting time of 4 hours in A&E from arrival to admission, transfer or discharge

98.9%

98.61%

97.14%

95.99%

95.09%

94.9%

% diagnostic achieved within 6 weeks

96.5%

97.50%

99.96%

99.6%

99.76%

99.8%

Certification against compliance with requirements regarding access to health care for people with a learning disability

In addition to the national and local indicators the Trust includes the following data as quality indicators. The East Kent Hospitals University NHS Foundation Trust considers that this data is as described for the following reasons outlined in Table 17.

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quality report Part 4: Annexes Annex 1: Statements from the Council of Governors, Clinical Commissioning Groups, and Kent HealthWatch – Limited Assurance Report on the content of the Quality Report Incorporating guidance from the Department of Health’s Quality Accounts Regulations and Monitor we were advised to send our Quality Accounts to our lead commissioners, the Local Involvement Network, and our governors. The comments below are: Governors’ Commentary Priority 1 – Person-centred care and improving patient experience 1. The Friends and Family Test. This is a new national test of patient satisfaction, introduced to in-patient wards and A&E Departments in April 2013. Standards for response rates for Inpatients and A&E are set nationally .The test was also introduced into Maternity Units in October 2013. In East Kent it is a component of the CQUIN Schedule agreed with local CCG’s (as a ‘goal’ attracting a payment of £940.000 for “full” achievement). Initially Response Rates were very poor but following changes to the methods used (initiated by staff) these improved very significantly, meeting national standards for A&E, In-patient Wards and for the various stages of Maternity Care by 2014 and Scores (termed Net Promoter Scores) have also improved. Staff have found the scores and comments in the free text section very helpful in evaluating their care of patients and Governors understand that this Test is now well embedded and a very useful way of measuring patient satisfaction across different areas and specialisms. 2. Friends and Family – Staff The annual response rates for this are derived from the annual NHS Staff Survey “Overall Staff Engagement” Section Question KF24 “Would you recommend your Trust to others as a place of work and would you be happy with the standard of care provided by the Trust if a friend or relative needed treatment ?” This, in fact, consists of 2 questions and is, hence, ambiguous and a source of confusion to some staff, perhaps reflected in the relatively low positive response rates in this year (56.8% compared with the national average of 66.2%) – and in the previous year. Review of the wording of this Question for the coming year is recommended. Our HR Department is concerned about the Staff Engagement measures revealed overall in the Staff Survey and has set up a committee to report on this, as part of it’s “We Care” programme including the “In Your/Our Shoes”.

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3. Response Time for Formal Complaints Governors congratulate the Patient Experience Team (PET) on the considerable within-year improvement after a disappointing start to 2013/14, resulting from an increase in formal complaints and staffing problems within this team, towards the 85% target of response times to formal complaints received by the complainant within the agreed time. Though the annualised standard of 85% was not achieved, by February 2014, the monthly % response rate had risen to 84.8%. Governors have chosen “Response Times for Formal Complaints” as their Local Indicator for 2014/15 and will continue to monitor the monthly Clinical Quality & Patient Safety Performance

Summaries, in the expectation of this improvement being maintained and the Standard achieved, holding the PET to account for this. 4. Cancer Waits All seven Cancer Targets were met, with the exception of 62 day waits for Screening Referrals at the threshold of 90%, where for two Quarters at 87.77% and 77.46% this was not achieved. The anxieties experienced by patients and those close to them during these waiting periods for diagnosis and then treatment or re assurance are fully understood by staff and managers of the Trust. East Kent has an exceptionally high and rising referral rate for possible Cancer patients. Governors have met with Clinical Nurse Specialists from those departments not meeting the 62 day target and they have explained their action plans to meet this challenge with more efficient procedures, enhanced staff and diagnostic and therapeutic facilities. Governors therefore anticipate compliance with all seven targets this year. 5. Safeguarding Adults & Children EKHUFT work described by the report, related to Adult Protection and those with Learning Disabilities, is proactive, comprehensive and, in some areas, innovative. Increased education for staff, linked to the Mental Capacity Act, is linked to the CQUIN target for this area. An increase in referrals to Independent Mental Capacity Advocates (IMCA) has been attributed to the education initiatives. It would be interesting to know if the IMCA service has the capacity to respond appropriately to the increase in referrals. In the area of Safeguarding children identification and referrals have also increased significantly. The report says that the Safeguarding Children Team (SCT) is working, to identify link nurses across the Trust, to provide a more seamless service. They are also gathering evidence to support expansion of the SCT. Safeguarding Children is everyoneâ&#x20AC;&#x2122;s concern yet there is no discussion, of the successful increased education or raising awareness to all staff, as with Adult Protection & Learning Disabilities. Priority should be given to eliminating any gaps in the safeguarding process, including education, and raising awareness in all staff. The PAS electronic flagging system demonstrates a useful and effective way of ensuring interagency communication. Governors will commit to examining Safeguarding as a major priority in 2014/15. 5. Cleanliness The Patient Led Assessments of Care Environment (PLACE) provided a Framework for inspecting standards in specific areas: Cleanliness, Food, privacy & dignity and general maintenance/decor. Unfortunately the Trust was 10% lower than the National Score on cleanliness but, more positively, identification will enable it to take remedial action towards improving the score. It was disappointing that the Trust was lower than the national average in three of these important areas. It did exceed the target on food and there was considerable improvement from the previous year. Priority 2 â&#x20AC;&#x201C; Safe Care by improving patient safety and reducing harm 6. Safe Care Priority We aimed to achieve the DH improvement trajectory for MRSA (Zero tolerance for avoidable infections and C.difficile infections= 29 post 72-hours. Eight MRSA infections and 49 C.diff. infections occurred. Two of the MRSA infections were considered to be avoidable. Seven C.difficile cases were assessed as avoidable or were non compliant with Trust Policy. The Governors are pleased to note that the priority for next year is to achieve zero

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quality report tolerance of avoidable MRSA and achievement of trajectories for C.difficile, noting that these have been set at a more realistic level, and E.coli rates, by improved infection prevention. Governors hold the work of the Trustâ&#x20AC;&#x2122;s Infection Prevention & Control Team in high regard and take considerable assurance from their efforts and achievements. Category 2 avoidable hospital acquired pressure ulcers totalled 95 during 2013/14, which is within the local target reduction of 25% from last year (No more than 131). It is disappointing that the local target to reduce Category 3 and 4 pressure ulcers by 50% was not met and that, in fact, numbers increased by approximately 10% from 28 to 31. Again, the priority for 2014/15 is to reduce categories 2/3/4 pressure ulcers. Prevention of pressure ulcers depends crucially on provision of considerable intensive nursing skills which can only be provided through appropriate nursing skill-mix and sustained staffing levels and these will continue to be monitored by the Governorsâ&#x20AC;&#x2DC; Patient and Staff Committee on a regular basis. 7. Improving Safety and Reducing Harm We are pleased to note the plans for full implementation of the new Falls Risk Assessment and Care Plan following publication of NICE Guidance on Prevention of Falls in Older People (June 2013) and the educational events to be planned by the Harm Prevention Action Group. Although there has been a downward trend in total number of falls and those falls resulting in fractures over the past five years, there has been an increase in both falls and falls resulting in fractures over the last year. During 2014/15 using the Falls Risk Assessment and Care Plan, compliance will be reviewed stringently. Mandatory Falls Prevention Training is being continued and achievement in this will be monitored. 8. Never Events Governors have confidence that the responses to the three identified never events in 2013/14 will ensure that actions have been put into place to establish that reasons for their occurrence will not recur. Trust protocol as recommended by NHS England, audit to ensure that theatre staff adhere to the count process and to appropriate, informed consent prior to any procedure, will be monitored by the CoG PSE Committee. Priority 3 â&#x20AC;&#x201C; Effective Care by improving clinical effectiveness and reliability of care 9. Staff Development and Staffing Levels Effective care is rooted in competent, compassionate staff with enough time to carry out their work effectively. There are plans to make improvements in the Staff appraisal process. The last staff survey indicated that this was among the top 5 areas of compliance. It would be useful to know whether issues for development, identified at previous appraisals by staff and managers, have been given the necessary approval, time and funding.

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There were a number of comments suggesting non-compliance with Trust policy which had an unwanted effect on patient care e.g. linked to MRSA infections. There was also an increase in Category 3 & 4 pressure ulcer targets. This is mentioned previously under Priority 2 where it stated that, prevention of pressure ulcers does depend upon considerable labour intensive nursing skills. One of the targets for person centred compassionate care was to improve the essential aspects of nursing care, with focus on pain management, nutrition and hydration. Targeting these issues indicates a possible lack of education and training or probable insufficient staffing levels

Parallel to the Trust monitoring of ward establishment staffing levels, the Governors (Patient & Staff Experience Committee) continue to focus on actual staffing levels. The Trust, as with others in the South East, has continuing nursing recruitment challenges. Recent recruitment has expanded include nurses from Spain and Portugal. 10. Beds At the start of this year (2013/14) all three main hospitals came under unprecedented pressures on their beds, resulting from increase in admissions and delays discharging treated patients because of lack of capacity in the community. The Trust had no alternative but to declare this as a Major (Internal) Incident in April. They subsequently mobilised all their resources to clear beds safely and restore normal emergency and elective services. Staff and Managers reacted magnificently and both normal elective and normal service overall was restored rapidly. Lessons were learnt and these were applied in time to prevent a recurrence this winter. The Trust continues to work with those organisations, in the wider health community, to improve overall capacity in East Kent as a major priority. The external factors impacting on our Capacity resulted in Extra Beds, Outliers, Delayed Transfers of Care and excessive Bed Occupancy Figures. These factors had an inevitable impact and contributed to the Trustâ&#x20AC;&#x2122;s inability to achieve targets for 2013/14. There has been a reduction of Hospital at Home beds and inability to achieve the target bed numbers for the Health & Social Care Village There has been an increase in unplanned re-admissions within 30 days of discharge, deterioration in the waiting list and planned admissions and deterioration in the times patients wait to get a bed on the ward. Linked together this data implies a lack of bed capacity. It would be interesting to know more about the future plans for implementation and then audit of Ambulatory Care Pathways and results/recommendations of audit/patient satisfaction on those pathways already in place. This is an area where Governors could usefully be involved in the coming year. Priority 4 â&#x20AC;&#x201C; An effective workplace culture that can enable and sustain quality improvement 11. Education & Training There is mention of staff involved in Venous Thromboembolism (VTE) having access to a mandatory e-learning programme. Innovative planned developments include a repository of resources, tools and the virtual team of people to support the work of the Quality Improvement and Innovation Hub (QIIH). The QIIH have planned a number of other potentially important educational initiatives. It would be useful to know how they will be implemented and if they will be prioritised as part of staff development with adequate time allocation. The report makes a number of claims, many of which are substantiated, but in places lacks detail on how they would be measured or implemented. The Council of Governors EKHUFT 12 May 2014

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quality report Healthwatch Kent response to the Quality Account for East Kent University Hospital Foundation Trust As the independent champion for the views of patients and social care users in Kent we have read the Quality Accounts with great interest. Our role is to help patients and the public to get the best out of their local health and social care services and the Quality Account report is a key tool for enabling the public to understand how their services are being improved. With this in mind, we enlisted members of the public and Healthwatch staff and volunteers to read, digest and comment on your Quality Account to ensure we have a full and balanced commentary which represents the view of the public. On reading the Accounts, our initial feedback is that the accounts are very lengthy and not written in plain English making this hard for the general public to read, understand and digest. This is not a problem unique to East Kent as we have seen similar issues with all the Quality Accounts from Kent providers. For future reports we would like to work with you, and other providers, to ensure the reports are accessible and understandable for a wider audience. For this year, a list of acronyms would help. The report references engagement with the public and patients. There is mention of an engagement plan for reaching out to seldom heard groups which we of course welcome. We would like to hear more detail about how you are working with patients and the public and would be happy to help you to develop ideas for the year ahead as this is such a vital part of your work. We note in the report the positive news that you have recently recruited a new Head of Patient Involvement and we have already made contact with her. We hope this will bring about significant developments in the way you work, with and involve, patients in the development and improvement of services. Healthwatch Kent has recently signed a Memorandum of Understanding with East Kent University Hospital Foundation Trust. The agreement pledges our support to help the Trust develop a meaningful conversation with the public. As part of that we would like to offer our help and support to develop a better, more meaningful Quality Account for next year which can truly help the public understand your achievements and priorities. We have a group of volunteers who could be a willing test bed for this. In summary, we would like to see more detail about how you involve patients and the public from all walks of life in decisions about the provision, development and quality of the services you provide. We hope to continue and develop our relationship with the Trust to ensure we can help you with this. Healthwatch Kent 20 May 2014 Commentary from Commissioners Clinical Commissioning Groups Statement in relation to the 2013/14 Quality Account for East Kent Hospitals University Foundation Trust (EKHUFT) The four Clinical Commissioning Groups covering East Kent, comprising of NHS Ashford Clinical Commissioning Group, NHS Canterbury and Coastal Clinical Commissioning Group, NHS South Kent Coast Clinical Commissioning Group and NHS Thanet Clinical Commissioning Group are the leading commissioners for East Kent Hospitals University Foundation Trust (EKHUFT).

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South Kent Coast Clinical Commissioning Group and Thanet Clinical Commissioning Group Dear Stuart Bain Response to EKHUFT Quality Account 13/14 On behalf of Thanet CCG and South Kent Coast CCG I would like to thank you for submitting your draft Quality Account for review. The East Kent University Hospitals Foundation NHS Trust Quality Account has been circulated to the CCG’s Governing Body members and member practices for comment. I believe the account includes the mandated elements required and represents a fair position of the work of the Trust as reported to its commissioners. I have reviewed the data presented and am satisfied it is in line with the information supplied by East Kent University Hospitals Foundation NHS Trust during this year and reviewed as part of your performance under your contract with NHS Thanet CCG and NHS South Kent Coast CCG, hosted with Canterbury and Coastal CCG. As indicated by the Trust in their Quality Account the Care Quality Commission (CQC) inspected William Harvey Hospital, Kent and Canterbury Hospital and Queen Elizabeth the Queen Mother hospital sites in March 2014. The CQC have not yet published their judgement on the quality and safety of services following this inspection. The CCGs are therefore not in a position to comment on the outcome of the inspection. CQC inspections findings are part of the quality assurance framework for commissioners informing their opinion alongside all other safety, effectiveness and patient experience information about the Trust’s quality of services. The priorities have been developed in line with the Trust’s Quality Strategy and through consultation with service users and staff. Going forward the CCGs would welcome the Trust seeking their input in addition to service users and staff when considering future priorities. The Quality Account is written in an accessible way for the public audience and provides clarity for the reader regarding which priorities have been delivered. The CCGs recognise the significant work undertaken by the Trust to strengthen their use of patient and staff engagement to set the organisational values and welcomes this as a key driver for quality improvement. The Trust has set itself a large number of quality process and outcome priorities to deliver in 2014/15. The CCG would welcome, for a number of the priorities, them being further strengthened with clear measurement and description of why the priority would improve patient safety and quality. Thanet CCG and South Kent Coast CCG are committed to working collaboratively with the Trust during 2014/15 to deliver whole health system quality improvements for our residents. This will be achieved through clinicians from organisations working collaboratively. Accountable Officer for NHS Thanet CCG and NHS South Kent Coast CCG 22 May 2014

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quality report Dear Stuart Bain Response to EKHUFT Quality Account 13/14 On behalf of Ashford and Canterbury & Coastal CCGs, I would like to thank you for submitting your draft Quality Account for review. The East Kent University Hospitals Foundation NHS Trust Quality Account has been circulated to the CCG’s Governing Body members and member practices for comment. I believe the account includes the mandated elements required and represents a fair position of the work of the Trust as reported to its commissioners. I have reviewed the data presented and am satisfied it is in line with the information supplied by East Kent University Hospitals Foundation NHS Trust during this year and reviewed as part of your performance under your contract with NHS Ashford and Canterbury & Coastal CCGs, hosted with Canterbury and Coastal CCG. As indicated by the Trust in their Quality Account the Care Quality Commission (CQC) inspected William Harvey Hospital, Kent and Canterbury Hospital and Queen Elizabeth the Queen Mother hospital sites in March 2014. The CQC have not yet published their judgement on the quality and safety of services following this inspection. The CCGs are therefore not in a position to comment on the outcome of the inspection. CQC inspections findings are part of the quality assurance framework for commissioners informing their opinion alongside all other safety, effectiveness and patient experience information about the Trust’s quality of services. The priorities have been developed in line with the Trust’s Quality Strategy and through consultation with service users and staff. Going forward the CCGs would welcome the Trust seeking their input in addition to service users and staff when considering future priorities. The Quality Account is written in an accessible way for the public audience and provides clarity for the reader regarding which priorities have been delivered. The CCGs recognise the significant work undertaken by the Trust to strengthen their use of patient and staff engagement to set the organisational values and welcomes this as a key driver for quality improvement. The Trust has set itself a large number of quality process and outcome priorities to deliver in 2014/15. The CCG would welcome, for a number of the priorities, them being further strengthened with clear measurement and description of why the priority would improve patient safety and quality. Ashford and Canterbury & Coastal CCGs are committed to working collaboratively with the Trust during 2014/15 to deliver whole health system quality improvements for our residents. This will be achieved through clinicians from organisations working collaboratively. Chief Nurse for NHS Ashford and Canterbury & Coastal CCG 22 May 2014

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Annex 2: Statement of Directors’ responsibilities in respect of the Quality Accounts The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports (which incorporate the above legal requirements) and on the arrangements that foundation trust boards should put in place to support the data quality for the preparation of the Quality Report. In preparing the Quality Report, directors are required to take steps to satisfy themselves that: •

the content of the quality report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2013/14;

•

the content of the Quality Report is not inconsistent with internal and external sources of information including: -

Board minutes and papers for the period April 2013 to March 2014; Papers relating to Quality reported to the Board over the period April 2013 to March 2014; Feedback from the commissioners 22 May 2014; Feedback from governors dated 12 May 2014; Feedback from local Healthwatch organisations dated 20 May 2014; The trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated May 2104; The 2013 national in-patient survey; The 2013 national staff survey; The Head of Internal Audit’s annual opinion over the trust’s control environment dated 12 May 2014; CQC quality and risk profiles dated April 2013 to September 2013; Intelligent Monitoring Reports October 2013 to March 2014.

•

the Quality Report presents a balanced picture of the foundation trust’s performance over the period covered;

•

the performance information reported in the Quality Report is reliable and accurate;

•

there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice;

•

the data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and the Quality Report has been prepared in accordance with Monitor’s annual reporting guidance (which incorporates the Quality Accounts regulations) (published at (available at www.monitor.gov.uk/annualreportingmanual) as well as the standards to support data quality for the preparation of the Quality Report (available at (available at www.monitor.gov.uk/annualreportingmanual)).

The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report. By order of the Board

Chairman 22 May 2014

Chief Executive 22 May 2014

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quality report Trust directors

Julie Pearce Chief Nurse and Director of Quality & Operations

Dr Paul Stevens Medical Director

Jeff Buggle Director of Finance and Performance Management

Liz Shutler Director of Strategic Development and Capital Planning

Peter Murphy Director of Human Resources and Corporate Services

134

2013 -14 LIMITED ASSURANCE OPINION ON THE CONTENT OF THE QUALITY REPORT AND MANDATED PERORMANCE INDICATORS Independent Auditor’s Report to the Council of Governors of East Kent University Hospitals NHS Foundation Trust on the Quality Report We have been engaged by the Council of Governors of East Kent University Hospitals NHS Foundation Trust to perform an independent assurance engagement in respect of East Kent University Hospitals NHS Foundation Trust’s Quality Report for the year ended 31 March 2014 (the “Quality Report”) and certain performance indicators contained therein. Scope and subject matter The indicators for the year ended 31 March 2014 subject to limited assurance consist of the national priority indicators as mandated by Monitor: • Clostridium Difficile – all cases of Clostridium Difficile positive diarrhoea in patients aged two years or over that are attributed to the Trust; and • 62 Day cancer waits – the percentage of patients treated within 62 days of referral from GP. We refer to these national priority indicators collectively as the “indicators”. Respective responsibilities of the Directors and auditors The Directors are responsible for the content and the preparation of the Quality Report in accordance with the criteria set out in the NHS Foundation Trust Annual Reporting Manual issued by Monitor. Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that: • the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual; • the Quality Report is not consistent in all material respects with the sources specified in section 2.1 of Monitor’s 2013/14 Detailed Guidance for External Assurance on Quality Reports; and • the indicators in the Quality Report identified as having been the subject of limited assurance in the Quality Report are not reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual and the six dimensions of data quality set out in the Detailed Guidance for External Assurance on Quality Reports. We read the Quality Report and consider whether it addresses the content requirements of the NHS Foundation Trust Annual Reporting Manual, and consider the implications for our report if we become aware of any material omissions. We read the other information contained in the Quality Report and consider whether it is materially inconsistent with: • Board minutes for the period April 2013 to May 2014; • Papers relating to Quality reported to the Board over the period April 2013 to May 2014; • Feedback from the Commissioners dated May 2014; • Feedback from local Healthwatch organisations dated May 2014; • The Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, 2013/14; • The 2013/14 national patient survey; • The 2013/14 national staff survey; • Care Quality Commission quality and risk profiles 2013/14; and • The 2013/14 Head of Internal Audit’s annual opinion over the Trust’s control environment. We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with those documents (collectively, the “documents”). Our responsibilities do not extend to any other information. We are in compliance with the applicable independence and competency requirements of the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised assurance practitioners and relevant subject matter experts.

135

This report, including the conclusion, has been prepared solely for the Council of Governors of East Kent University Hospitals NHS Foundation Trust as a body, to assist the Council of Governors in reporting East Kent University Hospitals NHS Foundation Trust’s quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended 31 March 2014, to enable the Council of Governors to demonstrate they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of Governors as a body and East Kent University Hospitals NHS Foundation Trust for our work or this report save where terms are expressly agreed and with our prior consent in writing. Assurance work performed We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 (Revised) – ‘Assurance Engagements other than Audits or Reviews of Historical Financial Information’ issued by the International Auditing and Assurance Standards Board (‘ISAE 3000’). Our limited assurance procedures included: • Evaluating the design and implementation of the key processes and controls for managing and reporting the indicators. • Making enquiries of management. • Testing key management controls. • Limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation. • Comparing the content requirements of the NHS Foundation Trust Annual Reporting Manual to the categories reported in the Quality Report. • Reading the documents. A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement. Limitations Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of established practice on which to draw allows for the selection of different but acceptable measurement techniques which can result in materially different measurements and can impact comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision thereof, may change over time. It is important to read the Quality Report in the context of the criteria set out in the NHS Foundation Trust Annual Reporting Manual. The scope of our assurance work has not included governance over quality or nonmandated indicators which have been determined locally by East Kent University Hospitals NHS Foundation Trust. Conclusion Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2014: • the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual; • the Quality Report is not consistent in all material respects with the sources specified above; and • the indicators in the Quality Report subject to limited assurance have not been reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual. KPMG LLP Statutory Auditor Chartered Accountants 15 Canada Square Canary Wharf London E14 5GL 23 May 2014 136

directorsâ&#x20AC;&#x2122; report

137

directorsâ&#x20AC;&#x2122; report

Executive Directors and Non Executive Directors who served during 2013/14 Board Member

Term of office ends

Nicholas Wells, Chairman Jonathan Spencer, Deputy Chairman and Senior Independent Director Valerie Owen, Non Executive Director Christopher Corrigan, Non Executive Director Richard Earland, Non Executive Director

03/09/15 13/13 31/10/14 12/13 30/11/15 13/13 31/12/15 10/13 31/12/16 13/13 (Reappointed from 1/1/14) 30/09/15 11/13 28/02/16 12/13 n/a 12/12 Retired as Medical 2/2 Director May 2013 Appointed from June 2013 10/11 n/a 13/13 n/a 12/13

Peter Presland, Non Executive Director Steven Tucker, Non Executive Director Stuart Bain, Chief Executive Dr Neil Martin, Medical Director and Deputy Chief Executive (Acting Chief Executive 11 April 2013 to 12 May 2013) Dr Paul Stevens, Medical Director Jeff Buggle, Director of Finance and Performance Management Julie Pearce, Chief Nurse and Director of Quality and Operations Deputy Chief Executive from June 2013 Liz Shutler, Director of Strategic Development and Capital Planning Peter Murphy, Director of HR and Corporate Services

n/a n/a

Board of Director attendance record*

12/13 11/13

* Directorsâ&#x20AC;&#x2122; attendance at all 13 meetings of the Board held during the year (actual and possible, is shown).

138

Our Board of Directors Nicholas Wells, Chairman Nicholas Wells has been a Non Executive Director of the Trust since November 2001 and was appointed as Chairman in September 2008. His professional background as a health economist involves more than 30 years experience working in commercial, public and academic settings and publishing nearly 100 papers on health care economics policy and planning issues. Significant commitments of the Trust Chairman include: Non Executive Director, York University Health Economics Consortium; Visiting Professor at the London School of Pharmacy; and Non Executive Director of Active Life. Christopher Corrigan, Non Executive Director Christopher Corrigan was first appointed in January 2009. Christopher is a Professor of Asthma, Allergy and Respiratory Science at King’s College Hospital, London, based at Guy’s Hospital. Chris has over 100 original publications in the field of asthma and allergy research and manages a large adult allergy service based at Guy’s Hospital. He is also interested in undergraduate and postgraduate medical education. He is currently chair of the Royal College of Physicians Specialist Advisory Committee on Allergy and Immunology. Richard Earland, Non Executive Director Richard Earland was appointed in January 2011. Richard’s background includes public sector experience in defence, health and policing, spanning 39 years. Valerie Owen, Non Executive Director Valerie joined the Board in December 2008, and was previously a Director of international real estate consultants Jones Lang LaSalle. By profession, she is a Chartered Architect, Development Surveyor, Town Planner and Environmentalist, specialising in complex community regeneration and sustainable development projects. She serves on Boards for a variety of public and private sector organisations including Defence Infrastructure Board, Church Buildings Council, Hanover Housing and the Planning Inspectorate. She chairs the Sector Skills Council for land-based and environmental industries, and was awarded an OBE in 2001 for services to architecture and to the community in east London. Peter Presland, Non Executive Director Peter Presland was appointed in October 2012 and is Chairman of the Integrated Audit and Governance Committee. Peter is a law graduate (LL.B. Hons.) and an Associate of the Institute of Chartered Accountants in England and Wales (A.C.A.). He has over 40 years financial experience working in the City of London, initially within the audit division of a major professional services firm and later in commerce, at CFO, CEO and Chairman level on the Boards of quoted companies. Since 2001, he has pursued a portfolio career, acting as a Non Executive Director or Chairman for a variety of IT and financial services companies. From 2003 to 2008, he was the first independent Chairman of LINK, the UK ATM banking network, where he led a programme of substantial corporate governance reform. Jonathan Spencer, Deputy Chairman/Senior Independent Director/Non Executive Director Jonathan Spencer was first appointed as Non Executive Director in November 2007. He was appointed as Senior Independent Director from 2 March 2009 for the period of his tenure and as Deputy Chairman from November 2010. By profession, he was a Senior Civil Servant, including Board membership of the DTI and DCA (Department of Constitutional Affairs), and now has a portfolio of Non Executive interests in the public and private sectors. Steven Tucker Steven Tucker was appointed in March 2013. Steven’s background includes public sector experience in construction, regeneration and housing, at Director, Chief Executive and consultancy level.

139

directorsâ&#x20AC;&#x2122; report Stuart Bain, Chief Executive Stuart Bain, Chief Executive, joined the Trust in August 2007 from NHS National Services Scotland where he was Chief Executive. Stuart has experience of operating at Board level since 1986 when he joined Redbridge Health Authority as Director of Planning and Estates. He subsequently has been Chief Executive of three different NHS boards over a period of 23 years. Jeff Buggle, Director of Finance and Performance Management Jeff Buggle, Director of Finance and Performance Management, joined the Trust in 2011. Jeff is a certified accountant with 18 years experience working at Board level in the NHS. He has previously been a Finance Director at a number of other organisations including a Foundation Trust and two teaching hospitals, as well as for the NHS in Wales. Peter Murphy, Director of Human Resources and Corporate Services Peter Murphy, Director of Human Resources and Corporate Services, joined the Trust in 2000 and was appointed to the Director position in 2002. Previously, he was a Lieutenant Commander in the Royal Navy. Peter is a graduate Member of the Institute of Personnel and Development and has a MBA. Julie Pearce, Deputy Chief Executive/Chief Nurse and Director of Quality and Operations Julie Pearce, Chief Nurse and Director of Quality and Operations, joined the Trust in 2007 and became Deputy Chief Executive in June 2013. Julie is a Registered Nurse with 30 years experience of working in the NHS, including 15 years as an Intensive Care Nurse. She has had previous experience of working at Board level in an acute Trust and a Strategic Health Authority and was Nursing Advisor to the Department of Health for Acute and Specialist Services between 2001-2003. Julie has joint accountability for Patient Safety and Clinical Quality with the Medical Director. Liz Shutler, Director of Strategic Development and Capital Planning Liz Shutler, Director of Strategic Development and Capital Planning, joined the Trust in January 2004. Liz has over 20 years experience of working for the NHS and has held Director level positions in Health Authorities and large acute Trusts. On appointment, Liz led one of the largest reconfigurations of services to be undertaken at that time in the country and has gone on to lead the development of the Estates & Facilities and IT services. Dr Paul Stevens, Medical Director

Paul Stevens joined the then Kent and Canterbury Hospitals NHS Trust from the Royal Air Force in 1995 as Clinical Director of the Kent Kidney Care Centre, implementing a programme of modernisation and development and establishing a predominantly clinical research programme in kidney disease. He has served on deanery, national and college Committees, is a former President of the British Renal Society and member of the Department of Health Renal Advisory Group. He was clinical advisor and chair of a number of National Institute for Health and Care Excellence (NICE) Clinical Guidelines and was a member of the UK consensus panel for management of Acute Kidney Injury. He was also privileged to have co-chaired the international Kidney Disease Improving Global Outcomes (KDIGO) Chronic Kidney Disease guideline. He has published over 100 peer reviewed articles and given invited presentations to kidney societies around the globe. In April 2014 he was awarded the International Distinguished Medal by the United States National Kidney Foundation in recognition of significant contributions to the field of kidney disease internationally.

140

Research & Development The National Institute for Health Research (NIHR) is the Englandwide organisation that directs and funds clinical (ie, people, as opposed to laboratory, based) research in the NHS. High quality research studies that are funded by major funding bodies or charities, or that are funded by industry partners, are 'adopted' onto the NIHR Portfolio. The current year has seen major gains for research, development and innovation in East Kent Hospitals University NHS Foundation Trust. Surveys tell us that patients and the public want their local NHS organisations to be active in research and innovation, and many people want the opportunity to participate in research studies. By the end of March 2014 we will have recruited approximately 1500 participants to NIHR Portfolio studies. This represents a 25% increase on the previous year, which is a tremendous achievement for all those involved. Other notable achievements by colleagues include: • • •

A major innovation award to Dr Jeremy Bland (Consultant Neurophysiologist) for his Carpal Tunnel website Publications in major medical journals, for example Dr Chris Pocock (Consultant Haematologist) in The Lancet Award of a £2 million grant from the NIHR Health Technology Assessment Programme to Dr Edmund Lamb (Consultant Clinical Biochemist) who is Chief Investigator for a pan-UK multi-centred prospective study in people with chronic kidney disease.

Compared with last year we saw a 13% increase in new non-industry NIHR Portfolio studies being approved by the Trust and a 10% increase in publications in peer-reviewed journals. We have received very significant increases in researchrelated income (£2.45m vs. £1.47m last year). The only objective that we failed to achieve this year was to increase numbers of new industry studies by at least 10% - overall we opened 10 in this year compared with 14 last year. Last year, and along with other NHS organisations, we were the subject of an NIHR 'mystery shopper' exercise. The 'shoppers' told us that the visibility of our research to patients & public wasn't as good as it could be. Over the past year, we have worked hard to deliver new patient-facing R&D webpages, which you can find at www.ekhuft.nhs. uk/research. This will be followed by a major awareness raising and publicity campaign amongst patients, public and colleagues later in 2014. In addition, we have brought a patient and public representative onto the Trust's R&D Committee and Internal Grant awarding panel, and we will soon be looking for volunteers to act as 'Patient Research Ambassadors' to help us promote the benefits of getting involved in research. We are setting up a Quality Improvement & Innovation Hub as a 'onestop-shop' resource for staff. Central to the Hub is the integration of research and inquiry with development and improvement activities. The Hub will provide easy access to the resources, expertise, mentorship, programmes and templates required to build on organisational activities. We have continued to develop and strengthen our partnerships with local Universities (Universities of Kent & Greenwich and Canterbury Christ Church University) through various joint initiatives, co-hosted symposia, co-funded studentships and academic collaborations. Two of this year's Kent Health PhD studentships were awarded to clinical co-supervisors in the Trust. We will be building on these achievements as we go into 2014/15 with the intent of developing more jointly funded positions between Universities and Trust to more firmly embed research, innovation and inquiry at the centre of what we do. 141

directors’ report

Our staff At the end of 2013/14, we employed 7403 people, who all contribute to our aim of making sure every patient feels cared for, safe and confident that we are making a difference. Listening to and involving our staff is important to us, and in 2013 we increased our efforts in ‘ward to Board’ communication by beginning a ‘walk the floor’ programme, whereby directors visit wards and departments on a regular, informal basis, and regular ‘open door’ sessions, where directors take time out to make themselves available for staff in all areas of the organisation to pop in, ask questions and give their views. We provide regular information for our staff on the Trust’s performance (including financial performance) and new developments. We use a variety of ways to give this Information about information - from a weekly newsletter, the composition of an online news site that staff can access our workforce can anywhere, at any time, a monthly briefing for all teams to discuss, a bibe found on p23 monthly staff forum hosted by the Chief Executive and Staff Zone - our intranet. We are also using different social media to communicate and converse with staff. We also continued our ‘staff listening meetings’ on a quarterly basis following the success of the first round of these meetings in early 2013 to discuss the Trust’s response to the Francis report. Engaging and consulting with our trade union colleagues is also really important to us. This year we embarked on reviewing back office services and through staff involvement and engagement of regional officers we have agreed to an “in house” bid for improvements to equipment management, hard FM and procurement services. Our staff Committee (the consultative Committee of managers and trade union representatives) came to a negotiated agreement in year on implementing new incremental pay arrangements. As well as having an active staff Committee, a number of our Divisional Directors meet regularly with their local representatives to talk about improving efficiencies, care for patients and responding to staff concerns.

Sickness absence rate

142

Employee sickness absence levels remained at a similar level to 2012/13 at 3.7%, 1.75% relating to short-term absence and 1.95% relating to long term absence. Supporting staff health and wellbeing is important to us - information about our Occupational Health service is on page 143.

Our policies for recruiting and continuing employment of disabled people • Recruitment & Selection Toolkit • Recruitment And Selection Policy • Sickness Absence Managers Toolkit • Sickness Absence Policy • Delivering Performance Policy • Flexible Working Policy • Managing Change Policy And Procedure • Grievance Procedure • Parking Policy • Disciplinary Procedure • Special Leave: A Toolkit For Managers And Staff

Improving staff health & safety Many departments have achieved significant improvements in the standards of documented systems, procedures and other precautions, which must be achieved to adequately control health, safety, fire and security in a department. The Health & Safety Executive (HSE) visited our premises on several occasions this year. No notices were issued. We introduced a 24/7 security guard service this year, which is popular with staff, patients and visitors. Staff Non Clinical Incidents 2013/14 Accident / Fall (staff or visitors only) Breach of confidentiality/data protection/computer misuse Facilities / Estates issues Fire including false alarm Manual handling Security Transport issues

605 2 253 131 91 908 531

Occupational health & wellbeing Our Occupational Health Service is accredited through the Safe Effective Quality Occupational Health Standards - an assured scheme managed by the Royal College of Physicians. The Trust service was very well evaluated this year and described as “one of the best” by the assessors. The service aims to: • Promote health and wellbeing • Prevent ill health caused or exacerbated by work • Timely intervention, easy and early treatment of absence • Rehabilitation, helping staff to remain in work, or to return to work safely • Health assessments at work, helping managers to manage absence • Teaching and training, promoting health with managers and staff. Over 700 staff took part in our ‘Take 5’ health and well being programme in 2013. We also launched a new employee assistance programme which operates 24/7 and offers advice on coping with difficult incidents as well as wider help such as debt counselling. The annual staff flu vaccination programme was also very successful this year. Fifty percent of staff were vaccinated - a rise of 12% on last year’s figure.

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Staff survey A sample of our staff were surveyed as part of the 2013 national NHS staff survey. Our response rate was 50% which was an improvement from the previous year and was average when compared with acute trusts in England. A breakdown of our top and bottom ranking scores when compared with other acute trusts in England is shown below: 2012/13

2013/14

Top 4 ranking scores

Trust

National average

Trust

National average

% improvement / deterioration

Percentage of staff appraised in last 12 months

88%

84%

90%

84%

No statistical change

Fairness and effectiveness of incident reporting procedures

3.52

3.50

3.58

3.51

No statistical change

Percentage of staff experiencing discrimination at work in last 12 months

12%

11%

No statistical change

Percentage of staff experiencing physical violence from staff in last 12 months

No statistical change

Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months

28%

24%

31%

24%

No statistical change

Percentage of staff suffering workrelated stress in last 12 months

39%

37%

44%

37%

No statistical change

Percentage of staff able to contribute towards improvements at work

62%

68%

60%

68%

No statistical change

Percentage of staff feeling pressure in last 3 months to attend work when feeling unwell

32%

29%

34%

28%

No statistical change

Bottom 4 ranking scores

There has been no statistical change in our results when compared to previous years, except in response to the percentage of staff receiving jobrelevant training, learning or development, which has shown an improvement to 80%. This was a bottom ranking score in 2012 so it is good to see the organisation has made progress in this area. The Board of Directors has committed to focus on improving engagement with staff over the coming year.

144

how the Trust is run

The Board of Directors Our Board of Directors has overall responsibility for the operational and financial management of our Trust. It is responsible for the design and implementation of agreed priorities, objectives and for developing our strategic direction. Our Board is required to comply with its Standing Orders, Standing Financial Instructions and the Terms of its Provider Licence issued by Monitor, the sector regulator for Foundation Trusts. Our Board of Directors operates according to the highest corporate governance standards. Whilst it delegates day-to-day operational management to our Chief Executive and Executive Directors, there is a formal schedule of matters reserved for the Board. Set out in our standing orders and scheme of delegation are those decisions delegated by our Board of Directors to Trust management. A copy is available on the Trust’s website www.ekhuft.nhs.uk. The composition of our Board of Directors is specified in our Constitution. Our Board of Directors comprises the Chair, six Non Executive Directors and six Executive Directors. Our Board of Directors also has a Deputy Chairman who also serves as our Senior Independent Director. In accordance with our Constitution, Non Executive Directors are appointed by our Council of Governors. Non Executive Directors are appointed for a three year term and re-appointment may be considered for a further three year term. Non Executive Directors may in exceptional circumstances serve longer than six years but will be subject to annual appointment serving up to a maximum of three further years (making nine years in total). Our Council of Governors also set our Non Executive Directors’ remuneration and conditions of office. Non Executive Director appointments may be terminated if individuals become ineligible to hold the position during their term of office, details of which are set out in our Constitution. Terms of office may be ended by a resolution of our Council of Governors following the provisions and procedures laid down in our Constitution. The appointment of our Chief Executive is by our NonExecutive Directors, subject to ratification by our Council of Governors. Our Board is of sufficient size that the balance of skills and experience is appropriate for the requirements of our business and our future direction. Arrangements are in place that enable appropriate review of our Board’s balance, completeness and appropriateness to the key

priorities of our Trust. As at 31 March 2014, all of our Board positions were substantive and there were no vacancies. Based on criteria set out in Monitor’s Code of Governance, our Board of Directors considers all of our Non Executive Directors to be independent. The professional background of each member of our Board of Directors (and terms of office of each NonExecutive Director) as at 31 March 2014 is presented on page 139. Our Board of Directors’ links to our Council of Governors and Trust membership are described on page 156.

Board of Director meetings Our Board routinely meets every month or otherwise as required and in accordance with Standing Orders. The Agenda is balanced to ensure that adequate time is devoted to strategic, operational and financial matters with a strong focus on the quality and safety of clinical services. We held 13 Board of Director meetings during 2013/14. Meetings were held in public, with the exception of meetings held in June and September which were designated Away Days and an extraordinary meeting held in February 2014. Attendance records for all of our Board members can be found on page 146. Our Board has established a number of sub-Committees which meet regularly throughout the year to undertake work delegated from the Board. Board Committees are chaired by our Non-Executive Directors and our Board of Directors receive reports at each meeting. Board Committees in place as at 31 March 2014 are: • Finance and Investment Committee • Integrated Audit and Governance Committee • Remuneration Committee • Nominations Committee • Charitable Funds Committee. A list of membership and attendance for our Statutory Committee is documented on page 146. Our Board meeting papers and Board Committee terms of reference are published on the Trust’s website www. ekhuft.nhs.uk.

145

how the Trust is run

Board Committee Membership and attendance record Board Member

Integrated Audit and Governance Committee Member

Attendance Record*

Nicholas Wells, Chairman

Nominations Commitee Member

Attendance Record*

Committee did not meet

Jonathan Spencer, Deputy Chairman and Senior Independent Director

5/6

Committee did not meet

Valerie Owen, Non Executive Director

5/6

l (Chair until July 2013)

Committee did not meet

Christopher Corrigan, Non Executive Director Richard Earland, Non Executive Director

4/6

l (Chair from July 2013)

Committee did not meet

Peter Presland, Non Executive Director

l (Chair)

6/6

Committee did not meet

Steven Tucker, Non Executive Director Stuart Bain, Chief Executive

n/a

Dr Neil Martin, Deputy Chief Executive and Medical Director (Retired May 2013)

n/a

Dr Paul Stevens, Medical Director (From June 2013)

n/a

Jeff Buggle, Director of Finance and Performance Management

n/a

Julie Pearce, Chief Nurse and Director of Quality and Operations Deputy Chief Executive (from June 2013)

n/a

Liz Shutler, Director of Strategic Development and Capital Planning

n/a

Peter Murphy, Director of HR and Corporate Services

n/a

* Attendance out of total meetings held during 2013/14 (possible and actual, is shown). It is a statutory requirement to report att

Evaluation of Performance All of our Executive and Non Executive Directors undergo annual performance evaluation and appraisal. Executive Directors have an annual appraisal with our Chief Executive and our Chief Executive is evaluated annually by our Chairman. The outcomes of our Executive Director appraisals are provided to Non Executive Directors at a meeting of the Remuneration Committee. The performance of Non Executive Directors is evaluated annually by our Chairman, drawing on information from 146

the Council of Governors and executive colleagues. The annual appraisal of our Chairman is led by our Senior Independent Director who seeks the views of our Non Executive Directors, Executive Directors and Council of Governors. The outcomes of our Chairman and Non Executive Director appraisals are provided to a part II/ closed meeting of our Council of Governors. Our Board of Directors undertakes an annual review of its own collective effectiveness. During 2013/14, members of our Board of Directors completed a board evaluation survey and the results were reviewed at a Part II/Closed session of our Board of Directors meeting held in March 2014. This yearâ&#x20AC;&#x2122;s evaluation included a significant section

Remuneration Committee

Finance and Investment Committee

Charitable Funds Committee

Attendance Record*

Member

3/3

l (Chair until July 2013)

2/3

l (Chair)

Member

l (Chair until July 2013) l l (Chair from July 2013)

3/3

l (Chair from July 2013)

1/3

3/3

1/3

0/3

n/a

3/3

n/a

tendance at Integrated Audit & Governance Committee, Nominations Committee and Remuneration Committee only. on quality (Board engagement; accountability; and managing risks). In addition the survey addressed board focus, structure (including Committee effectiveness), processes, andf relationships (internal and external).

Executive Directors who are not members of these Committees to ascertain an independent view of effectiveness. All of our Board Committees undertake an annual review of their terms of reference.

Board performance is evaluated further through focused discussions at our Board Away Days, Strategic Meetings and on-going in-year review of our Board Assurance Framework.

Board of Directors register of interests

Our Integrated Audit and Governance Committee and Finance and Investment Committee carry out annual reviews of effectiveness through a questionnaire to the membership and subsequent evaluation. A questionnaire is also circulated to our Executive Directors and Non-

All members of our Board of Directors are required to declare other company directorships and significant interests in organisations which may conflict with their Board responsibilities. A register of our Directorsâ&#x20AC;&#x2122; interests is available on the Trust website â&#x20AC;&#x201C; www.ekhuft.nhs.uk 147 A

how the Trust is run

Board Committee reports Integrated Audit and Governance Committee (IAGC) All NHS Foundation Trust Boards of Directors are required to establish an Audit Committee. It is the Board’s responsibility to have in place sufficient internal control and governance structures and processes to ensure that the Trust operates effectively and meets its objectives. An Audit Committee, or in this case an Integrated Audit and Governance Committee, is a suitably qualified and dedicated body, which supports the Board by critically reviewing those structures and processes upon which the Board relies, and provides the whole Board with an assurance that this is what is happening in practice. The IAGC advises the Board on the robustness and effectiveness of the Trust’s systems of internal control, risk management, governance and systems and processes for ensuring, among other things, value for money. The Committee has authority to receive full access to information and the ability to investigate any matters within its terms of reference, including the right to obtain independent professional advice. It has no executive powers. The IAGC comprises four Non-Executive Directors. To ensure the proper segregation of duties, the Trust Chairman cannot be a member of the IAGC. The Committee Chairman is a member of the Institute of Chartered Accountants in England and Wales and has recent and relevant financial and audit experience. Two Executive Directors and the Trust Secretary also regularly attend the meetings by invitation, and the Trust’s Chief Executive is invited to attend at least once a year when the Annual Governance Statement is discussed. The main role and responsibilities of the IAGC are set out in written terms of reference which detail how it will monitor the integrity of the financial statements, review the Trust’s internal controls, governance and risk management systems, and monitor and review the effectiveness of the Trust’s audit arrangements including those covering clinical audit. The Committee aims to ensure that the same level of independent scrutiny and audit over controls and assurances is applied to all risks to the achievement of objectives, be they clinical, financial or operational. The Board Assurance Framework is a document, prepared by and on behalf of the whole Board, that 148

brings together the Trust’s objectives and targets, the associated risks, the controls in place to manage those risks, the reliability of information to monitor progress, and the sources of assurance to the Board that the Trust’s objectives will be achieved. In order to review and support the Annual Governance Statement (see page 166) and the Annual Quality Report (on page 47), the IAGC has, on behalf of the Board, regularly reviewed the Board Assurance Framework, Corporate Risk Register, the Quality Risk Profile and the Intelligent Monitoring Report, and considered recommendations from the Trust’s auditors in relation thereto. The IAGC’s relationships with the Trust’s internal and external auditors and counter-fraud consultants are central to its role, as they provide independent assurance and insight into the robustness of the Trust’s management processes. Specialist firms perform both the internal and external audit and the counter-fraud functions, and representatives from all three such firms regularly attend IAGC meetings to outline their work programmes and to present their findings. In addition, they meet separately with the Committee Chairman on a regular basis to cover potentially sensitive issues and to ensure that their independence is maintained. Additionally, this year saw the final year of appointment of the Trust's current external auditors. The Committee's Chair led a project group, which conducted a selection process which resulted in the re-appointment of the Trust's external auditors, KPMG, for a further minimum term of three years. The Council of Governors endorsed a recommendation of appointment from the Audit Working Group at their January 2014 meeting. The IAGC works closely with the Audit Working Group (a representative body of the Council of Governors) in the appointment and on-going monitoring of the external auditors, and presents an Annual Report to the Council of Governors. The Committee has received regular assurance reports from management, for example on whistle-blowing policies, mandatory training for staff, patient survey results, tendering, losses, information governance, safeguarding children and adults, the work of the Drugs and Therapeutics Committee, health and safety and estates compliance, and other areas where specific action may be required. Reports are received on relevant matters discussed at the Executive-led Clinical Management Board and Risk Management & Governance Group. The IAGC receives reports on the

Trust’s compliance with Care Quality Commission and NHS Litigation Authority standards, and ensures that reports from other external bodies are properly considered and any recommendations responded to in an appropriate and timely way. The Committee receives regular technical briefings in order to remain up to date with current requirements. The Committee has continued the programme of ‘deep dives’ into specific areas of risk from the Corporate Risk Register. Detailed presentations are received from service managers and clinical leads, giving IAGC members extra time to probe into current and potential risk and control issues and receive a better understanding of service issues. The Committee then ensures that there are follow ups on previous deep dives, and in the coming year there are follow ups scheduled around health records, patient flows/patient safety and patient transport. The 2013/14 IAGC programme also included reviews of the Trust’s responses to the Francis Report, of clinical coding, of complaints and of health records. The forward plan includes potential deep dives into telephony issues, business continuity and disaster recovery, as well as a review into the circumstances behind the award of the Picture Archiving & Communication System/Radiology Information System (PACS/RIS) contract. Additionally, the IAGC meets jointly with the Finance & Investment Committee each May to receive the audited financial and quality accounts and reports, together with feedback from the external auditor. Additional Joint Committee meetings take place twice a year where selected clinical divisions present and receive questions on their activity, financial performance, business developments and future plans, service quality (safety, effectiveness and experience) and audit, risk and governance issues. Following each IAGC meeting, the Committee Chairman presents a summary of key issues and matters to be addressed to the next meeting of the Board of Directors for consideration, action and support.

Finance and Investment Committee (FIC) The Finance and Investment Committee of the Board, which comprises at least three Non-Executive members of the Board (including the Chair) together with the Chief Executive and the Director of Finance and Performance Management, oversees the Trust’s financial strategy, financial policies, financial and budgetary planning, monitors financial and activity performance and reviews proposed major investments (and can approve some under the Trust’s scheme of delegation). The Committee continues to focus its work around five main areas: • Development and maintenance of the Trust’s medium and long term financial strategy • Review and monitoring of financial plans and their link to operational performance • Financial risk evaluation, measurement and management • Scrutiny and approval of business cases and oversight of the capital investment programme • Oversight of the finance function and other financial issues that may arise. In August 2013 the Committee reviewed the proposed financial strategy for the Trust for 2014 to 2019. At a national level the outlook for the NHS had been described as “the toughest financial climate ever known” and Monitor advised acute trusts to expect a significant national efficiency requirement each year up to 2016 and potentially beyond. In addition to national economic pressures, Clinical Commissioning Groups (CCGs) are beginning to operate their commissioning role to move work out of the acute sector and into a community setting. In addition CCGs are implementing change, including the opening up of services to alternative providers as well as imposing contract penalties for missed targets. The Trust must generate sufficient surplus year on year to maintain an essential and substantial programme of capital investment, while maintaining and improving the quality of service offered to patients. The strategy approved by the Committee and the Board envisages a challenging Cost Improvement Programme of almost £80m over the three year period 2014-17 with a £26.8m target for 2014/15. This would deliver a small deficit in 2014/15 due to one off charges for the building of Dover Hospital but would allow the Trust to return to surplus by 2015/16 and maintains the top rating according to Monitors new financial stability measure. This strategy would also permit capital expenditure at the required level to maintain service for the foreseeable future. During 2013/14, the Committee has reviewed monthly monitoring material covering activity, clinical performance and financial performance including savings, both for the Trust as a whole and also broken down by division. 149

how the Trust is run

In general, activity was planned to be slightly increased compared with the previous year. In the event, the activity has been even higher than planned driven largely by increases in non elective work and increases in day case work particularly in Ophthalmology. Whilst other Trusts in the local health economy have struggled to meet their financial targets the Trust’s financial performance for 13/14 has been an underachievement of £2.3m vs plan for Earnings Before Interest, Tax, Depreciation and Amortisation. This has been driven mainly by the high cost of supporting the high level of non-elective work with temporary staffing. The Committee monitored financial performance monthly, and the £30m Cost Improvement Programme (CIP) in particular. The Trust has had difficulties implementing some of the planned procurement and workforce schemes but has managed to deliver £26.2m of savings in 2013/14 and increased the percentage of schemes which produce recurrent savings when compared to prior years. The Committee, jointly with the Integrated Audit and Governance Committee, has embedded a rolling programme of twice yearly presentations from clinical divisions, focused on, but not limited to, financial performance, quality and other challenges.

The Committee reviewed the outcome of business cases approved in the previous financial year, for example VitalPACTM. The capital investment programme for 2013/14 has been managed close to the Capital plan. The building of Dover Hospital has commenced this year and is on track to finish in 2014/15. In addition the FIC reviewed plans for the integration of pathology services between the Trust and Maidstone and Tunbridge Wells NHS Hospital Trust and the final business case was approved this year. In addition business cases in relation to the Francis report were also considered and increased staffing was approved for adult and paediatric wards. In December, the Committee reviewed in depth the budgetary plans for 2014/15, consistent with the financial strategy agreed earlier in the year, and embedding the ambitious CIP plans for the year in the divisional elements of the plan. Contract negotiations were held with Clinical Commissioning Group representatives during the first quarter of 2014 and a workable plan was developed.

150

Charitable Funds Committee East Kent Hospitals Charity raises funds for the wards and services provided by the Trust. The generous gifts and donations enable the Charity to improve the environment, purchase some of the latest equipment and support research projects. The Charitable Funds Committee oversees the strategy, financial business and governance of the Charity under written Terms of Reference on behalf of the Board of Directors who retain the responsibility for achieving the Charity’s objectives as agents for the Corporate Trustee. Meetings are held quarterly and attended by professional advisors, such as the Investment Managers, as appropriate. The Charity holds assets of £4,314,422 and received donations and legacies totalling £294,205 in 2013/14. Every single donation is appreciated and has enabled the Charity to support a number of significant projects and help purchase additional equipment and improvements to hospital facilities. This year has seen the completion of the three year major Appeal for Breast Cancer with all the equipment identified in the business plan purchased and in situ. The success of the Appeal, which formally closed in June 2013, continues to accept donations which will enable additional equipment to be purchased in support of breast cancer. Despite the continuing difficult financial climate, the Charity has been able to support various projects to benefit the patients and visitors who use our hospitals. Grants totalling £632,145 were given to the Trust this year and included the following projects: • Tomosynthesis & workstations for Digital Mammography £205,000 • Additional Telemetry channels for ECG monitoring WHH £ 55,996 • Colposcopy stack system – BHD £ 42,024 • Heart Research projects - WHH & K&C £ 41,122 • Simulation Mannikin for NICU ‘real life’ training – QEQM & WHH £ 11,946 • Refurbishment of Haemophilia garden – K&C £ 11,435 With continuing pressures on the NHS to deliver increasingly sophisticated medical treatments with ever greater demands on services, charitable donations remain vitally important in helping the Trust provide the best medical diagnosis, treatment and facilities for its

patients. The Charity continues to work closely with other charities and organisations like the Leagues of Friends and Cancer Care Club that support the Trust to provide both new and replacement equipment and to improve the environment in which our patients and visitors are treated. The Trustees together with the staff on the wards would like to thank all our donors, fundraisers, business partners and other charities for continuing to support the patients at our hospitals.

Combined Remuneration Committee and Nominations Committee Report The Remuneration & Nominations Committee met twice in the financial year 2013/14 with a further meeting of the remuneration Committee in February 2014. In July 2013 the Committee reviewed the performance of the executive team for the year 2012/13 and asked the Chief Executive to feedback their appreciation to the executives of the work done in the year. They also considered the objectives set for 2013/14 and asked the Chief Executive to make some amendments to reflect issues they had raised in regard to aligning strategy across the organisation and its functional areas, nominating a single lead for the clinical strategy and ensuring the CQC were specifically referred to in the objectives of the executives. The Committee agreed that executive pay should be benchmarked as part of the annual review of the pay policy for 2014/15. They also asked the Chief Executive to notify them of appointments and resignations at the level below director. At the November meeting it was agreed to separate the Remuneration and Nominations Committee and terms of reference were updated accordingly. The Committee considered reports from the Chief Executive and Chairman on the mid-year review of performance of the Executive. The Committee noted the importance of maintaining strong leadership to enable the Trust to address the sustainability agenda and recognised the challenging portfolios of the executive team. The importance of the effective working of the top team was also noted. The Chief Executive was asked to work with his team to undertake 360 degree feedback as part of 2013/14 performance review. The Committee considered the resignation of the Director of Human Resources and Corporate Services, the Chief Executive explained he was seeking to bring together a number of aspects of workforce such as all education commissioning within the role. It was agreed a job description would be brought to the February Committee with the aim of advertising no later than March 2014.

February 2014â&#x20AC;&#x2122;s meeting considered a further amendment to the Nominations Committee terms of reference, ensuring that there was a meeting at least once a year that would consider the skills, experience and roles at the Board. This was in response to a change in the Monitor Code of Governance. The Pay policy for senior managers and the policy for determining remuneration and performance of executive directors were both reviewed with external advice from the HAY group. The Committee considered the advice and agreed an uplift to the pay range in the senior manager pay policy to reflect the national changes made for Agenda for Change staff. The Committee did not receive a report on any pay increases for the senior managers as these had not yet been agreed by the Chief Executive and Director of Human Resources. The Committee considered the draft job description for the Director of Human Resources and asked for some changes to be made. They also reviewed pay for the Executive and came to the decision that a cost of living uplift of 1% should be awarded to all the executives, from 1 April 2014, subject to the same uplift being applied to all staff in the organisation. The Committee considered issues of pay across the executive and determined that a further review for at least one of the posts may be required when the Director of HR was appointed.

Nominations Committee The Nominations Committee of the Board of Directors fulfils the role described in the Trustâ&#x20AC;&#x2122;s Constitution and the NHS Foundation Trust Code of Governance and is responsible for the appointment of executive directors. In February 2014 it was agreed that the Nominations Committee would meet at least once every year to review the structure, size and compositions of the Board of Directors and to make recommendations on changes, where appropriate, as well as evaluating the balance of skills, knowledge and experience of the Board of Directors. The first of these meetings will take place in May 2014.

151

how the Trust is run

Remuneration report The Remuneration Committee agrees the remuneration and terms of service of the Executive Directors. HAY group were engaged to provide advice to the Committee on benchmarking of pay for executive directors and on the review of the senior manager pay policy for 2014/15. They were selected by the Head of Human Resources, who provides advice to the Committee, as part of the Committeeâ&#x20AC;&#x2122;s work to ensure external benchmarking is undertaken at least every three years. HAY were selected on the basis that they have wide ranging experience within the public and private sector and can apply the HAY group method of job evaluation to the roles to support their advice. The fee for the report provided to the Committee was ÂŁ4,500. The Committee approved the policy for determining the remuneration and performance management of executive directors for 2014/15 at its February 2014 meeting. There is no performance related component of remuneration. A determination was made as to whether a cost of living award should be paid based on national guidance and offers made to Agenda for Change and medical & dental staff. From 1 April 2014 this was a non-consolidated 1% of pay. Performance pay Performance of Executive Directors is monitored by the Remuneration Committee with reference both to individual performance appraisal and the broader performance of the Trust. There is no performance related pay or bonus available to the Executive Directors. Increases of pay, such as cost of living awards, are subject to the individual evidencing effective performance. Duration of contracts All Executive Directors have a substantive contract of employment with a three or six month notice provision in respect of termination. This does not affect the right of the Trust to terminate the contract without notice by reason of the conduct of the Executive Director. The Remuneration Committee is responsible for the annual review of the Pay Policy for Senior Managers and has regard for the pay range within this policy and national pay agreements when making decisions on pay for directors.

152

Senior Managers' salaries, expenses and non-cash benefits All figures are in £ thousands . Nicholas Wells

2013/14

2012/13

Salary

Other Remuneration

Benefits in kind

Salary

Other Remuneration

Benefits in kind

note 1

note 2

note 1

note 2

45-50

5-10

Richard Earland

10-15

5-10

Valerie Owen

10-15

Christopher Corrigan

Peter Presland

10-15

5-10

Jonathan Spencer

10-15

5-10

0-5

Steven Tucker Stuart Bain (note 3)

150-155

5-10

Jeff Buggle (note 4)

150-155 10-15

Neil Martin to 31/05/13 (notes 5 and 6)

2.8

170-175

5-10

3.3

5-10

150-155

5-10

0.0

0-5

120-125

20-25

1.5

Peter Murphy

100-105

0.4

Julie Pearce

125-130

0.0

Elizabeth Shutler

100-105

0.0

Paul Stevens from 01/06/13 (note 5)

160-165

Note: 1. Bands of £5,000 2. Taxable benefit on lease cars. 3. Break in service 12/04/13 to 12/05/13 inclusive. Other Remuneration in 2012/13 is payment for untaken annual leave. 4. Other remuneration is taxable travel allowance 5. Other Remuneration is for clinical work. 6. Also Acting Chief Executive 12/04/13 to 12/05/13. 7. Annual Accounts note 5.7 confirms that no other benefits or gains accrued to directors in either 2013/14 or 2012/13. Directors' expenses

2013/14

2012/13

Directors' mileage claims and other Total expenses are reported quarterly on serving the Trust website www.ekhuft.nhs.uk. directors

Number claiming expenses

Total expenses £000

Total serving directors

Number claiming expenses

Total expenses £000

Total number and value

16.9

14.8

Governors' expenses

2013/14

Total number and value

2012/13

Total serving governors

Number claiming expenses

Total expenses £000

Total serving governors

Number claiming expenses

Total expenses £000

1.8

1.4

153

how the Trust is run

Hutton Fair Pay review Organisations have to calculate the 'median remuneration' of their workforce each year - this is the whole time annual salary of an employee in the middle of the range of salaries paid to all our staff. We then compare this with the highest-paid director. The results are shown in the table below: 2013/14

2012/13

Remuneration of highest-paid director (bands of £5k)

190-195

175-180

Median salary of all other staff

£25,811

£25,714

Ratio

7.4 : 1

6.9 : 1

Definitions: The ratio is based on the mid point of the director's salary band. Total remuneration for this purpose includes salary, any non-consolidated performance-related pay, benefits in kind and any termination payments. It also includes an average value for agency staff. It excludes overtime payments, the transfer value of pensions, employer pension contributions and employer national insurance contributions. Using the above definitions, no employee received more than the highest paid director in 2013/14 or the previous year. Tax arrangements of public sector appointees During 2012/13 public sector bodies were notified of a new requirement relating to ‘off-payroll’ engagements for more than £220 a day and more than 6 months - The Trust is in the process of altering contracts to ensure that those relating to these appointments give the Trust the right to ask for evidence of a worker’s tax arrangements, and to end the contract if the response is unsatisfactory and/or report the matter to HMRC. The Trusts are required to include in this report both the position at 31st March 2014, and for new engagements since 1st April 2014. All off-payroll engagements as of 31st March 2014 , for more than £220 per day and that last more than 6 months

Trust

Number in place on 31/03/14

Of which: Number existing for less than 1 year

Number that existed between one and two years at time of reporting

Number that existed between two and three years at time of reporting

Number that existed between three and four years at time of reporting

For all new engagements, or those that reached 6 months in duration between 1/4/13 and 31/3/14 who are paid more than £220 per day and lasted longer than 6 months.

Trust

Number of new engagements 01/04/13 to 31/03/14

Of which: Number that include contractual clauses giving the right to request assurance in relation to income tax and NI obligations

Number for whom assurance has been requested

Of Which: Number for whom assurance received

Number that have been terminated as a result of assurance not being received

For any off payroll engagements of board members and/or senior officials with significant financial responsibility between 1/4/13 and 31/3/14

Trust

Number of off payroll engagements 01/04/13 to 31/03/14 board members and/or senior officials with significant financial responsibility between 1/4/13 and 31/3/14

Number of individuals that have been deemed "board members and/or senior officials with significant 0 financial responsibility" during the financial year. This figure should include both off-payroll and onpayroll engagements

154

Pension information is provided each year by the Pensions Division of the NHS Business Services Authority. Accounting policies for pensions are shown in the annual accounts notes 1.3 and 5.8. Pension Benefits of Senior Managers Name

Real increase/ (decrease) in pension at age 60

note 1

Real increase/ (decrease) in pension lump sum at age 60

note 1

Total accrued pension at age 60

Lump sum at age 60 related to accrued pension

Cash Equivalent Transfer Value

Opening CETV

at 31 Mar 2014

at 31 March 2013

note 2

note 3

Stuart Bain

Real Increase/ (decrease) in CETV

note 3

1,831

not applicable

Jeff Buggle

0.0-2.5

2.5-5.0

55-60

165-170

963

903

Neil Martin

not applicable

Peter Murphy

0.0-2.5

2.5-5.0

15-20

50-55

370

334

Julie Pearce

0.0-2.5

2.0-2.5

50-55

155-160

1,087

1,023

Elizabeth Shutler

0.0-2.5

2.5-5.0

25-30

85-90

458

426

Paul Stevens

2.5-5.0

12.5-15.0

45-50

140-145

1,052

891

122

All figures are in £thousands. No contribution was made by the Trust to a stakeholder pension. All the above are executive directors; Non Executive directors do not receive pensionable remuneration. Note: 1. Bands of £2,500 2. Bands of £5,000 3. Cash Equivalent Transfer Values: A CETV is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time, being the member’s accumulated benefits from their entire membership of the pension scheme including any contingent spouse’s pension payable. The value includes any ‘transferred-in’ service or purchase of added years by the individual. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries and represent the amount which can be taken by the member to another pension arrangement. The ‘real’ increase or decrease compared to the previous year takes account of inflation measured by the movement in the Consumer Prices Index. Signed:

Chief Executive 22 May 2014

155

how the Trust is run

Council of Governors Our Council of Governors comprises both elected (public and staff) and appointed governors and was first established in March 2009 following our authorisation as a Foundation Trust. Public and staff governors are elected from and by our Foundation Trust membership in accordance with the election rules as outlined in our Constitution. Appointed Governors are nominated by our key partner organisations. Our Council has specific responsibilities set out in statute which are: • The appointment (and removal if deemed appropriate) of our Chairman and Non Executive Directors and the setting of their remuneration and terms and conditions of service • Ratifying the appointment of our Chief Executive • The appointment of our external auditors. • Providing views on our forward plans and Annual Plans • Receiving our Annual Report and Accounts. The implementation of the Health and Social Care Act 2012 brought with it the following additional statutory roles and responsibilities: • To hold our Non Executive directors, individually and collectively to account for the performance of our Board of Directors • Represent the interests of our Foundation Trust membership and the interests of you, the public. • Approve any “Significant Transactions” (as defined by our Constitution) • Approve any application by us to enter into a merger, acquisition, separation or dissolution (in line with processes laid out in our Constitution) • Decide whether any of our non-NHS work would significantly interfere with our principal purpose, which is to provide goods and services for the health service in England, or performing its other functions • Approve amendments to our Constitution During 2013/14, our Chairman undertook a piece of work with a small working group of our Council of Governors to look at their new roles and how they can be applied locally. Our Chairman has also been working with our Trust Secretary to strengthen the Governors’ development programme. Our Board of Directors recognise the importance of ensuring services provided by us are developed to meet our users’ needs and reflect the views of our patients 156

and wider community. The following sets out steps taken by members of our Board of Directors to understand the views of our Governors and our Membership: • Our Board meetings are held in public and before each meeting we send a copy of the agenda to our Council of Governors. A copy is also published on our website. Our Council of Governors is also sent a confidential copy of our Part II/Closed meeting Board agenda to keep them abreast of all issues discussed by our Board of Directors • During 2013/14 we introduced a specific joint Governors/Non Executive Directors meeting which will take place on an annual basis. The meeting is chaired jointly by one of our Governors and a Non-Executive Director. This meeting will enable our Board of Directors to take account of Governor views, particularly with regard to quality priorities as our organisational forward plan is developed. This meeting is in addition to our annual joint Board of Directors/Council of Governors meeting • Our Council of Governors receive performance reports on a monthly basis. In addition, our Chief Executive provides an update on the latest Trust performance at each public meeting of the Council. Where performance concerns are identified by Governors, they can be raised at Council of Governor meetings, directly with our Chair (or at Board of Director meetings), or through our Council of Governor Committee structure • All members of our Board of Directors have an open invitation to attend Governors’ Council meetings to respond to questions on recent Board and Board Committee activity • The Board of Directors engage our Council of Governors on a variety of strategic issues formally at meetings and on an ad hoc basis. Our Council of Governors Strategic Committee undertakes a facilitative role on behalf of the full Council to respond to our key strategic documents • Our Council of Governors has established a number of substantive Committees to take forward key pieces of work. Committees will invite specific Directors or other members of our staff for particular agenda items driven by performance concerns, survey results, statutory visit outcomes or membership/public feedback. A Non-Executive Director has been linked to each of our Council of Governor Committees so that the relevant NonExecutive Director may be appraised of issues to be brought to the attention of our Board of Directors • Our Council of Governors has undertaken a programme of membership engagement events

throughout 2013/14 and has published two membership newsletters in 2013/14. Under the Health and Social Care Act 2012, Governors have the power to require one or more of the directors to attend a governors’ meeting for the purpose of obtaining information about the foundation trust’s performance of its functions or the directors’ performance of their duties. As mentioned above, Governors receive the Trust’s latest performance data as a standing agenda item. In addition, Governors are encouraged to put forward agenda items for their Council meetings and the following summarises agenda items requested during 2013/14: • A&E performance and assurances regarding the Trust’s seasonal plans • The Trust’s response to the Mid Staffordshire NHS Foundation Trust Public Inquiry • National Staff Survey Results and presentation of the Trust’s action plan • The outcome of the Trust’s annual Ward Establishment Review and the impact on service provision • The outcome following implementation of the Trust’s ‘We care’ programme • Assurances regarding the delivery of the chemotherapy outreach service • The work of the Tissue Viability Team and latest pressure ulcer performance • Assurances regarding patient transport following the introduction of a Kent-wide contract • An update on performance and service delivery within maternity services following a service reconfiguration during 2012/13 • Updates on progress against the Trust’s action plans following a visit by the Health Education Kent Surrey and Sussex and Royal College of Surgeons and assurances regarding the future of high risk and emergency surgery • The Trust’s management of end of life care following the withdrawal of the Liverpool Care Pathway by the Department of Health • The work of the Trust’s marketing department • The Trust’s processes for reporting and monitoring clinical incidents.

Council of Governor elections and Governor changes Public and staff Governor elections to one third of the elected seats on our Council of Governors were held in February 2014. During 2013/14, two Governors resigned from our Council. In line with our Constitution, these positions remained vacant and the seats were included in the February 2014 elections. All vacancies were filled. The overall percentage of votes based on the number of members who were balloted was: • 1 Shepway position - 25% • 1 Ashford position - 20.09% • 3 Staff positions - uncontested • 1 Canterbury – uncontested • 2 Dover positions - uncontested • 2 Thanet positions - uncontested A list of all Governors who served during 2013/14 is detailed on page 158. Nominated Governor Composition Our Council of Governors undertook a review of its nominated Governor composition during 2013/14. As a result, the following seats were removed from the Council: • Kent and Medway NHS and Social Care Partnership Trust • NHS Kent and Medway PCT Cluster. Council of Governor Public Meetings Our Council of Governors met in public a total of five times during 2013/14. In addition, a joint meeting with our Board of Directors was held in October 2013 and a joint meeting with our Non-Executive Directors took place in February 2014. Both meetings were closed to the public. Details of all public meetings, agendas, minutes and papers can be found on the Trust website: www.ekhuft.nhs.uk.

Lead Governor Our Council of Governors has nominated a Lead Governor who, if necessary, has a particular role in communicating with Monitor on behalf of the full Council. As at 31 March 2014, Ken Rogers (Elected Governor – Swale) held this position. A process is in place to enable our Council of Governors to review this position annually. 157

how the Trust is run

Council of Governors who served during 2013/14 Constituency

Ashford Borough Council

Name

Jocelyn Craig Derek Light Junetta Whorwell Canterbury City Council Philip Wells Brian Glew Dee Mepstead Dover District Council Liz Rath Laurence Shaw Harry Derbyshire Carol George Martina White Shepway District Council John Sewell June Howkins Alan Hewett Swale Borough Council Ken Rogers Paul Durkin Thanet District Council Reynagh Jarrett Michael Lucas Vikki Fenlon Marcella Warburton Roy Dexter Staff Mandy Carliell David Bogard Alan Colchester Rev Paul Kirby Vikki Hughes Rest of England and Wales Eunice LyonsBackhouse University Representation Peter Jeffries Local Authorities Cllr Patrick Heath South East Coast Ambulance Geraint Davies Services NHS Foundation Trust Volunteers working with the Michael Lyons Trust NHS Kent and Medway PCT Karen Benbow Cluster Kent and Medway NHS Marie Dodd & Social Care Partnership Trust

Term of Office ends 28/29 February 2015 2015 2017 (Re-elected from 03/14) 2017 (Re-elected from 03/14) 2015 2015 2015 2014 Deceased 2015 (Resigned 11/13) 2017 (Elected from 03/14) 2017 (Elected from 03/14) 2017 (Re-elected from 03/14) 2015 2015 2015 2015 2015 2014 2015 (Resigned 08/13) 2017 (Elected from 03/14) 2017 (Elected from 03/14) 2017 (Re-elected from 03/14) 2017 (Re-elected from 03/14) 2015 2014 2017 (Elected from 03/14) 2015

5/5 4/5 5/5 5/5 5/5 5/5 4/5 1/3 0/2 1/1 1/1 5/5 3/5 5/5 4/5 5/5 4/5 4/4 0/2 1/1 1/1 5/5 5/5 5/5 3/4 1/1 5/5

2015 2015 2015

1/5 3/5 1/5

2015

4/5

2015 (Position removed â&#x20AC;&#x201C; 2013) 2015 (Position removed â&#x20AC;&#x201C; 2013)

0/1

* Attendance at meetings held during the year (actual and possible) is shown.

158

Attendance record at Council of Governor public meetings (See note to table)

0/1

Board of Directors attendance at Council of Governors meetings Attendance record for Council of Governor meetings 2013/14* Nicholas Wells, Chairman

5/5

Jonathan Spencer, Deputy Chairman and Senior Independent Director

4/5

Valerie Owen, Non Executive Director

1/5

Christopher Corrigan, Non-Executive Director

0/5

Richard Earland, Non-Executive Director

1/5

Peter Presland, Non-Executive Director

1/5

Steven Tucker, Non-Executive Director

3/5

Stuart Bain, Chief Executive

0/5

Dr Neil Martin, Deputy Chief Executive and Medical Director (Until June 2013)

1/1

Dr Paul Stevens, Medical Director (From June 2013)

3/4

Jeff Buggle, Director of Finance and Performance Management

3/5

Julie Pearce, Deputy Chief Executive and Chief Nurse and Director of Quality and Operations

2/5

Liz Shutler, Director of Strategic Development and Capital Planning

2/5

Peter Murphy, Director of HR and Corporate Services

3/5

* Attendance at meetings held during the year (actual and possible) is shown.

Council of Governors Committees and working groups Our Council of Governors has established a number of Committees. As at 31 March 2014, the following substantive Committees were in place: • Patient and Staff Experience Committee • Communication and Membership Committee • Nominations and Remuneration Committee (statutory) • Audit Working Group • Strategic Committee • Committee Chairs Meeting • Constitution Committee A Committee Chairs Meeting, led by the Trust Chairman, was established during 2013 and meets twice per year to enhance and improve the effectiveness of the Council of Governors and to support closer working relationships between the Council of Governors and our Non-Executive Directors. There is also the ability for our Council of Governors to establish specific task and finish groups as required.

All Committees are chaired by one of our Governors and our Trust staff attend in an advisory capacity. Terms of Reference and minutes of all Governor meetings are published on our website as another means of communicating Governor activities to the Trust membership and public.

Council of Governors register of interests A register of Governors’ interests is updated annually and is available on the Trust website: www.ekhuft.nhs.uk

Contacting members of the Council of Governors Governors may be contacted via the Trust’s Membership Office, 01843 225544 ext 62696, or through the membership area of our website www.ekhuft.nhs.uk/ members or by e-mailing foundationtrust@nhs.net

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Annual Members’ Meeting We held our Annual Members’ Meeting in October 2013. Approximately 150 members of the public, staff and representatives from other key stakeholders were in attendance. We presented our performance for the past year and the event provided the opportunity for the public to meet and ask questions of our Chairman, Chief Executive and Lead Governor. Details of all public meetings are available on the Trust’s website www. ekhuft.nhs.uk.

The Committee undertook a review of NED remuneration during 2013/14 and a recommendation was endorsed by the Council of Governors in March 2014 for a freeze on Non-Executive Director remuneration for a further year. In addition, the Council of Governors considered the level of mileage rates paid to Non-Executive Directors and agreed to reduce rates in line with the rate received by the Council of Governors. Details of all our Non-Executive Directors who served during 2013/14 can be found on page 139.

Nominations and Remuneration Committee Our Council of Governors Nominations and Remuneration Committee is a statutory Committee and makes recommendations to the Council of Governors on the appointment and/or removal of our Chairman and Non-Executive Directors. The Committee also provides advice to our Council of Governors on the levels of remuneration and allowances and other terms and conditions of office of our Chairman and other NonExecutive Directors. The Committee follows the ‘Guide to the Appointment of Non-Executive Directors’ which was reviewed during 2013/14 and endorsed by our Council of Governors in January 2014. The aim of this document is to help our Council of Governors, Chairman and Human Resources department by providing guidance on all of the actions that would need to be completed to ensure an effective appointments process. The Committee has this year recommended the reappointment of Richard Earland, Non-Executive Director, for a further three year term. When considering this re-appointment, the Committee took a number of different factors into consideration such as existing skills and expertise on our Board and the potential risks associated with losing continuity in the membership of our Board (particularly at a time of significant change in the NHS). The Committee, however, is also mindful of its responsibility to ensure an appropriate level of refresh and takes as its default position, unless there is compelling reasons to the contrary, that our Non-Executive Director positions should be subjected to competition at term expiry.

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Attendance record for Nominations and Remuneration Committee Ken Rogers (Chair)

3/3

Philip Wells

2/3

Michael Lyons

2/3

Mandy Carliell

1/3

Paul Durkin

2/3

Alan Hewett

3/3

Brian Glew

3/3

Trust Attendees Nicholas Wells (Chairman)

N/A

Peter Murphy, Director of HR and Corporate Services

N/A

* Attendance at meetings held during the year (actual and possible) is shown.

Council of Governors Committee Statements Strategic Committee The Strategic Committee reports to the Council of Governors on strategic issues. It has met six times over the past year. Constructive dialogue was further developed with members of the Trust's Strategic Development and Capital Planning Department and with Non Executive Directors, this being enhanced by the appointment of Jonathan Spencer as our "aligned' Non Executive Director. Main topics were: 1. Providing input into the Trust's Car Parking Strategy, as implemented over the past year. Members consider that this provides a fairer and more accessible experience for the public and for staff, and particularly welcomed the provision of a substantial number of additional slots (which, for staff, as from April 2014, will reduce expensive and frustrating waits for permits, for those meeting the criteria, from over a year to a few days). The Committee will continue to press for better access for people with disabilities at the three acute sites and also at those sites for outpatient care identified following the public consultation and for lower tariffs for patients requiring prolonged and frequent visits for treatment (eg, radiotherapy). 2. Members welcomed the Trust's Ward Establishment Review following the Francis Report, this resulting in a substantial additional financial commitment to additional nursing posts 3.The Outpatient Services Review was detailed and discussed with members throughout its development, thus enabling Governors to participate constructively in the ensuing public consultation, having reached agreement on the underlying principles and aims of this. Governors, coordinated by the Strategic Committee, provided the required written input following the termination of the public consultation, to the External Evaluator.

6. Governorsâ&#x20AC;&#x2122; responsibilities for private patient wing governance (Spencer Wing) were clarified, and it was confirmed that Governors' responsibilities in this area were confined to their statutory duties for ensuring that non-NHS activity was proportionate and did not impact detrimentally on local NHS care - and that a local agreement on assessment of this is required. 7. Members were given timely information on problems for patients and the Trust arising from contracts with external service providers for non emergency patient transport and for communication of radiology reports and had opportunities for comment . 8. Drafts of the Operational Plan were shared with members in March 2014 and a commentary ("Views") on these provided - on a "qualified" basis in view of this Plan not being available in final form. Forward Plans for 2014/15 : 1. Development of proposals to sustain safe surgical services will continue to be a focus for the Committee. 2. The Operational (Phase 1) 2 year Plan and the draft Strategic Plan (Phase 2) 5 year plan will be examined by the Strategic Committee in April 2014 for preparation of reports to the Council. 3. The implementation of the proposed Kent Pathology Partnership (if this is confirmed) will be scrutinised, noting failures of similar projects at other Trusts in recent years. 4. The development of the proposed Private Patient Strategy will be examined. 5. The Trust's response to the report following the March 2014 visits by the Care Quality Commission (expected by Governors end June 2014), including any strategic change and capital development issues will be examined. 6. Members will familiarise themselves with Tendering and Contracting arrangements involving the Trust as these develop with other NHS organisations and with the private sector in order to provide scrutiny, recognising problems which arose during the course of 2013/14, also seeking involvement as appropriate.

4. Members were informed regularly of proposed service developments, these included the Back Office Review and the proposals for the Kent Pathology Partnership, and were given opportunities to express concerns around these. 5. The attendance of the Chair of the Council of Governors and Board of Directors and of our aligned Non Executive Director allowed focused debate on the definitions of non-NHS Income and measurement of the possible impacts of private patent activity on NHS work and these discussions will continue into the next year. 161

how the Trust is run

Audit Working Group (AWG) The AWG normally meets twice yearly, in February and July. The February meeting is held to receive and discuss salient points in the work plan of the external auditors. The July meeting is scheduled to receive the external auditor’s opinion following the audit of the Trust’s end of year accounts and quality report. During 2013/14, the AWG met more regularly, as a result of the contract of services of the Trust’s current external auditors coming to an end. Although the Trust’s Integrated Audit and Governance Committee lead the process to appoint a successor, the final decision for the appointment or re-appointment of external auditors rests with the Council of Governors. In November and December 2013, a project group consisting of Governor members of the Audit Working Group, the Chair of the Integrated Audit and Governance Committee and members of the Trust’s finance and procurement departments was established. The project group short listed and interviewed companies bidding for the external audit contract against set criteria for appointment. Following much deliberation and due diligence, the project group recommended KPMG to the Council of Governors, for re-appointment as the Trust External Auditors. This recommendation was endorsed by the Council in January 2014. KPMG have additionally agreed to institute a training programme for governors and the Audit Working Group has been instrumental in receiving draft programmes for comment.

Communications and Membership Committee One of the key roles and responsibilities of Foundation Trust Governors is to represent the interests of members of the Trust as a whole, and of the public. This is set out in legislation. In order to do this successfully, we need to keep in touch with members and seek their views, and to feed back information about the Trust’s activities and plans. We attach a high priority to this work, as does Monitor, the organisation that regulates Foundation Trusts. The Communication and Membership Committee has the lead role in developing and implementing the Governors’ engagement programme. So how have we done this over the past year? An important element is a newsletter - “Your Hospital” – which is published twice a year in February and July and is sent to all members. It contains articles written by Governors – several of which specifically invite comments and views from members – as well as items produced by the Trust. We have a busy programme of events that provide for Governors and members, and the wider public, to meet face-to-face: • Each month we have a “Meet the Governor” session in one of the 5 hospitals which provides an ideal “drop-in” opportunity • We have attended each of the nine Health Roadshows held across the Trust’s area over the past year (and to which all members have been invited) and been available to share thoughts and views • A large number of Governors attended the Annual Meeting in October 2013. • We visit outside organisations and groups to talk about the role of members and Governors and have delivered three such presentations. With the exception of the Annual Meeting, between two and five of the 22 elected Governors have attended each event. Governors have also attended each of the Outpatient Services public consultation meetings organised by the Trust. These events are advertised in the newsletter and on the membership pages of the Trust’s website; and the website is our third means of keeping in touch. It tells members how they can contact Governors, it provides links to minutes of formal meetings and other relevant documents, and we have now started to run surveys to provide a further opportunity for members (and the wider public) to express thoughts and opinions.

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We are continually looking at new ways to establish even stronger links between Governors and members of the Trust.

Patient and Staff Experience Committee The Committee met 10 times during 2013/14 and has worked closely with our Associate Chief Nurse (Patient Experience) and since July with our newly appointed Deputy Chief Nurse and Deputy Director of Quality. The Committee’s main piece of work this year was completion of Part 2 of our Staff Engagement Project which was undertaken with the aim of improving the quality of care our patients receive.The results of Part 1 were presented last year and were also fed into the Trust’s ‘We care’ programme. Results from Part 2 (Maternity and Accident & Emergency) were presented to the Council of Governors in July 2013 and also at a Joint Meeting of the Council of Governors and Board of Directors in October 2013, together with the Trust’s Improvement Plan developed in response to our findings. The Committee has taken on a new role to undertake quarterly reviews of the Trust’s Clinical Quality and Patient Safety Reports and consider how the Trust is meeting the healthcare needs of people it serves. Dedicated meetings are arranged for the Committee to review any areas of concern Governors have within these reports. So far we have undertaken a deep dive into the 62 Day Cancer standard to understand why this is not being met in all specialties. We have also had updates on the Trust’s plans for dealing with extra beds, patient outliers, mixed sex accommodation and delayed transfers of care, linked to the Trust’s seasonal plan. The Committee also receives quarterly feedback from Governors who have participated in the Trust’s programme of Executive Patient Safety Visits. This programme has been established by the Trust for Executive Directors, Non-Executive Directors and Governors as a ‘Meet and Greet’ walk-around following the National Patient Safety First Campaign on Leadership for Safety to connect Board members and Governors with frontline staff. The programme provides opportunities for frontline staff to raise patient safety issues and to agree on actions to take forward improvements.

on other Trust groups: The We Care Steering Group, Standards Monitoring Group, Hydration Action Research Group, Francis Report Working Group and the End of Life Care Board. Our plans for 2014/15 will be dependent on the information arising from the Care Quality Commission’s visit to the Trust in March 2013 and Governors on the Committee are keen to work with the Trust on any areas of improvement related to patient and staff experience. In addition, the Committee has also expressed an interest in working with the Trust on improvement plans resulting from the National Staff Survey. The Council of Governors receives annual reports on the Trust’s Ward Staffing Reviews and the Patient and Staff Experience Committee has a particular interest in staffing in maternity departments. The Committee will also continue to review themes from Trust complaints on a regular basis.

Themes from Trust complaints has been a permanent agenda item and areas of concern have been discussed with the Deputy Chief Nurse. The Committee has also received the Trust’s Integrated Audit & Governance Committee’s deep dive into the Trust’s performance against response times to complaints and the associated recovery plan. The Committee also received an update on the new Patient Experience Team structure. This Committee, as well as the Council of Governors Strategic Committee, has long been involved in parking issues and we have reported the result of a survey we undertook with patients. We were therefore very pleased to receive the recent report from the Deputy Director of Estates & Strategies on the outcome of the review undertaken by the Trust for Patient and Staff Parking. Members of this Committee also represent Governors 163

how the Trust is run

Our members Our members help us understand the views and needs of the communities we serve. Who can be a member Membership is open to anyone over the age of 16 who lives in England or Wales. Public constituencies There are seven public constituencies - six are based on Local Authority Areas and the seventh - Rest of England and Wales - allows non-east Kent residents to become members and elect a governor: • Ashford • Canterbury • Dover • Shepway • Swale • Thanet • Rest of England and Wales. Staff constituency All staff on permanent contracts, or who are in continuous contracted employment with the Trust for over a year, are opted in to this constituency. Staff members cannot be concurrent members of any public constituency.

We gained 461 members this year

We actively recruited more members through a variety of recruitment events during 2013/14 and at 31 March 2014 our total membership stood at 18,187. 11,174 of these members were public members and 7,013 were staff members. Membership by public constituency as Communicating with and hearing from our members 31 March 2014 A number of ‘Meet the Governors’ sessions and events on health topics of interest to members were held in November 2013 and February 2014. 2013 2014 1880 2093 We have a ‘virtual panel’ of members who review 2013 551

2014 600

2013 3107

2014 3190 2013 1253

2013 1028

2014 1094

2013 883

2014 1354

2014 947

A twice-yearly newsletter is distributed to members in all local authority area constituencies and is also available on the members’ area of the Trust’s website www.ekhuft.nhs.uk/members.

Rest of England and Wales

2013 1870 164

2014 1896

and provide valuable feedback to the Trust on both pamphlets and policies. The governors have decided to extend this model to construct a separate (although not mutually exclusive) Members’ Panel who will be specifically recruited to provide feedback and advice to governors in their deliberations at Council of Governor meetings. Members will be invited to participate in this panel by e-mail.

% of total eligible population 31/3/2013 31/3/2014

Age of our members 31 March 2014 0-16 17-21

0.08

0.32

2.94

2.49

2.75

1.27

9,302 members 2.22 out of a population of 672,462

1.38

3.87

1.80

19.17

3.01

19.69

5.82

6.26

2.70

8,506 members 5.13 out of a population of 256,261

3.32

3.00

1.93

0.14

0.40

1.46

0.97

3.65

2.13

29 members out of a population of 9,154 1,040 members out of a population of 41,788

22+

7,195 members out of a population of 567,370

Ethnicity of our members 31 March 2014 White Mixed Asian Black Other

168 members out of a population of 9,345

496 members out of a population of 16,455 311 members out of a population of 5,341 57 members out of a population of 2,113

Socio-economic 31 March 2014 ABC1 C2 DE Not assigned

1,582 members out of a population of 82,123 689 members out of a population of 171,702 395 members out of a population of 0

Gender of our members 31 March 2014 Male

3433

Female

7,577

Not specified

162

Do you consider you have a disability?

Responses 31/3/2013 973

Responses 31/3/2012 1,034 165

how the Trust is run

ANNUAL GOVERNANCE STATEMENT 2013/14 1. Scope of responsibility As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of East Kent Hospitals University NHS Foundation Trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that East Kent Hospitals University NHS Foundation Trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum. 2. The purpose of the system of internal control The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an on-going process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of East Kent Hospitals University NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in East Kent Hospitals University NHS Foundation Trust for the year ended 31 March 2014 and up to the date of approval of the annual report and accounts.

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3. Capacity to handle risk As Chief Executive I have ultimate responsibility for the management of risk within the organisation. Executive responsibility for providing assurance on the management of risk has been delegated to the individual in the post of Chief Nurse and Director of Quality and Operations (CN/DQO) for the year 2013/14. In order to support this role, and recognising that risk management is a corporate responsibility, all executive directors carry functional accountability for maintaining robust systems of internal control and for providing assurance of their effectiveness through the governance structures embedded throughout the Trust. The CN/DQO is supported in her role by a dedicated senior risk management team and by the operational leads for risk management within each division. The same individual chairs a monthly Risk Management and Governance Group (RMGG) meeting which receives reports from directorates and divisions, and monitors all aspects of governance, including the Corporate Risk Register. The Trust Board’s Integrated Audit & Governance Committee (IAGC) has overarching responsibility for the review and scrutiny of the Trust’s internal control and risk management systems, including financial and clinical aspects. The Committee also regularly reviews the Board Assurance Framework (BAF) and Corporate Risk Register as set out in its annual work programme. Key issues and actions required are reported to the Trust Board following each meeting. All members of staff receive training to manage risk commensurate with their role and responsibilities and this requirement is articulated in all job descriptions. The training is achieved through subject specific risk management awareness sessions during corporate induction and as

part of mandatory training for all staff. This programme is supported by a range of specialist training to meet clinical, health and safety and other legislative requirements. This includes risk assessment and root cause analysis tools and techniques. This programme will continue to be developed throughout 2014/15 as part of the overarching strategy to embed lessons learned from incidents occurring in the organisation. Staff awareness is further enhanced through internal corporate, divisional and directorate publications outlining key risks and the actions taken to mitigate them, as well as regular reports on adverse incidents, claims and complaints. 4. The risk and control framework Risk Management Strategy The Trust has a comprehensive Risk Management Strategy, which sets out the overall vision and intention for the management of risk across the organisation. The strategy details the responsibility of the Board of Directors for the effective control of integrated governance corporately. Delegated authority is given by the Board of Directors to the IAGC for monitoring and receiving assurance on the effective management of risk. The existing Risk Management Strategy was reviewed by the RMGG and IAGC and approved by the Trust Board in November 2013. The key elements of the strategy continue to include the purpose of risk management, the authority of managers regarding the management of risk, the process of risk management, assurance, training and monitoring. The strategy also describes the responsibilities of all staff including risk assessment and risk reporting, as well as communicating the Board of Director’s attitude to risk, which is essential if decision-making is to be successful. Through the strategy this is made clear and is consistent with the strategic objectives for the

Trust. Risk appetite is a series of boundaries, which are authorised by the Board and by delegated authority, which guide all staff on the limits of risk they can take. In line with British Standard BS31100, the Trust is committed to not taking risks that affect the quality of care and the experience of every person accessing our services. To ensure that the Trust is better able to manage risks which may impact on public stakeholders and is providing an effective service, there is comprehensive communication and engagement, at a service and organisational level, with patients, members of the public, governors and voluntary and community organisations. The main objectives of the strategy are to provide a series of tools and processes that ensure, where possible, care is harm free and the Trust is not exposed to unmitigated or poorly understood risk. The BAF and Corporate Risk Register inform the Board, at quarterly and monthly intervals respectively, of the most significant risks, the control measures in place to mitigate the risks and assurance on the overall effectiveness of these controls. The Risk Register covers all areas including potential future external risks to quality and has clear subsequent ownership. The most significant risks affecting the Trust and recorded on the Corporate Risk Register over the year under review were: • Financial efficiency improvements and control • A&E performance standards • CCG demand management, contract negotiations and financial challenges • Patient safety, experience and clinical effectiveness compromised through inefficient clinical pathways and patient flow • Clinical and patient safety risk

•

• •

associated with the delayed implementation of the Picture Archiving and Communication System/Radiology Information System (PACS/RIS) Trust response to the reports into the provision of surgical services by the Royal College of Surgeons and HEKSS Achieving quality standards/ CQUINS Ability to maintain continuous improvement in reduction of HCAIs in the presence of existing low rates Transport Service delays following transition to a new national provider Business continuity and disaster recovery solutions for Trust wide telephony.

There was a comprehensive plan of action developed, in association with local acute Trusts within a consortium arrangement, regarding the PACS/ RIS implementation and contingency arrangements were identified in order to fill the additional staffing requirements, which were necessary following the change to the new system. The Trust requested a review of the current arrangements in place for the prevention and control of infections from Public Health England (PHE) in view of the inability to meet the very challenging in-year targets. No significant issues were identified. All the risks, apart from the 4 hour A&E performance targets, were managed as part of routine business without the requirement of high level and dedicated immediate action. In Q3 increased attendances at the A&E caused considerable pressures for the Trust which, despite significant actions, resulted in a failure of this standard for the quarter. The risk of this failure was however anticipated, reported to the regulator and managed internally through the Non Executive Director Governance Group. The Trust also has appropriate mechanisms in place for capturing front-line staff concerns including, an Executive Patient Safety Visit programme led

by directors and governors as well as a defined “Raising Concerns” policy. The Board Assurance Framework The BAF is a key tool by which the principal risks that could impact on the achievement of the Trust’s annual and strategic objectives are effectively monitored by the Board and its principal sub-Committees. In 2013/14 the Non Executive Director Sub-Committee continued to provide assurance on a quarterly basis to the Board on progress against the 18 week Referral To Treatment (RTT), cancer pathway and A&E targets. The BAF also provides assurance that effective controls and monitoring arrangements are in place. It is also the key document that underpins this Annual Governance Statement (AGS). Of the agreed fourteen annual objectives, thirteen were either partially or fully achieved. The Trust set itself an internal stretch target to improve readmissions and whilst good progress was made in-year the good performance seen in the first half of the year was not sustained. Work will continue into 2014/15 to identify how the Trust can make changes to meet this target. Corporate and Directorate Risk Registers Assessing the risks associated with delivering the Trust’s annual objectives and service development plans is a core component of all activity undertaken. The risk register assesses the likelihood and impact of the risks occurring and indicates the mitigating actions that will be taken. The corporate risks are reviewed by the Board monthly. Corporate, divisional and directorate risk registers are completed using a standard matrix outlined in the risk management strategy. Divisional and directorate management teams discuss risk and mitigating actions at their monthly governance meetings. Divisional and corporate directorates also present 167

how the Trust is run

their risk registers and action plans to the RMGG twice a year and discuss the top five risks every quarter at their executive performance review. Incident reporting All staff are encouraged to report incidents and near miss events, via an embedded electronic system, as part of the Risk Management Strategy (and recent staff survey results have shown the Trust as a good NHS performer in terms of the fairness and effectiveness of incident reporting procedures). Trends and themes on incidents are reported to the Board of Directors and the Clinical Management Board monthly. This information is augmented by a quarterly and annual aggregated report on incidents, complaints and claims, which outlines lessons learned from such events. Data Security The Trust recognises the importance of having robust systems in place to safeguard personally identifiable information. Information governance risks are included as part of the corporate risk register and reported to the Board and IAGC in accordance with policy. There was no significant breach of data security reported during the year. The Information Governance Toolkit programme of work has been monitored through the Information Governance Steering Group which reports to the RMGG. In addition reports have also been provided to the IAGC. The Trust completed its annual Information Governance self assessment and was able to evidence full compliance with the requirements of the Information Governance Toolkit to meet the Assurance Statement; we therefore do not believe that there is significant risk of the Trust losing personal data. The Trust successfully dealt with the 43 relevant requirements necessary to declare Level 2 compliance. 168

During the year the evidence against 10 criteria was reviewed by the Trusts Internal Auditors and they were satisfied with the level of assurance provided as part of the self assessment process. NHS Foundation Trust Governance Licence Condition As part of the Risk Assessment Framework there is a requirement to ensure the Trust continues to meet the governance condition within its Provider Licence. As such, the Trust must apply principles, systems and standards of good corporate governance that would reasonably be regarded as appropriate for a supplier of health care services to the NHS. The Board of Directors’ has received, discussed and approved the self-assessment against this condition in the form of the Corporate Governance Statement which also forms a part of the Annual Planning process. The Corporate Governance Statement sets out the following: • The governance structures and how the Trust measures the effectiveness of the Board, the Boards sub-Committee’s and the reporting lines; • How the Nomination Committee reviews the skill mix of the Board of Directors to assure that the Trust is wellled; • The systems and processes in place to ensure that timely and accurate information is provided to allow the Board to assess risks to compliance with its licence; and • The governance in place to ensure that the Board has oversight of the Trust’s performance. The Corporate Governance Statement was prepared by the Trust Secretary with input from all the Executive Directors. In addition

it was reviewed by the Corporate Performance Management Team, the Integrated Audit and Governance Committee and ultimately the Board during the last quarter of 2013/14. The Trust’s Internal Auditors carried out an audit on the internal processes taken to ensure that the Trust continues to meet its Provider Licence; this review received “significant assurance”. This, along with the internal governance processes, has provided assurance to the Board that the Corporate Governance Statement is robust. The main risk to the Trust Provider Licence is due to the Care Quality Commissions Inspection in March 2014 as the outcome is not currently known, the draft report was due on 17 April 2014 and once received there is a process in place to review for factual accuracy. In terms of mitigating the potential outcomes the Annual Plan has financial flexibility built in to ensure that the Trust can meet most challenges that it may face in 2014/15. Progress in other risk areas Progress has been made in a number of significant areas of risk. These include the following: • The Foundation Trust is fully compliant with the registration requirements relating to the Essential Standards for Quality and Safety of the Care Quality Commission (CQC). During the year the Trust was successfully re-inspected on the two moderate areas of non-compliance identified in 2012/13. • The Trust maintains the NHS Litigation Authority Level 3 compliance (highest level possible) for general risk management standards and Level 2 compliance in maternity risk management standards.

Equality, Diversity and Human Rights Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with. • There is a Board lead responsible for all equality and diversity and Human Rights issues. • An Equality Delivery System is in place and the Board receives an annual report to highlight any issues identified from a service and employer perspective. As part of this process the organisational assessment of compliance in this area is agreed with local stakeholder groups. • The Trust has an established Equality, Diversity and Human Rights Steering Group, which meets every two months in order to embed equality, diversity and Human Rights into service development and future planning initiatives. • All approved policy documentation is required to have an Equality and Human Rights Analysis. • There is a dedicated equality and diversity manager in post to provide operational support to the Board of Directors. • The National Staff Survey results show the Trust as an above average performer in terms of equality and diversity training for the workforce. NHS Pension Scheme As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments in to the Scheme are in accordance with

the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations. In addition this year the Trust has taken all the necessary measures to comply with the new pension auto-enrolment requirements. Carbon Reduction The Trust has undertaken risk assessments and Carbon Reduction Delivery Plans are in place in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects, to ensure that this organisation’s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with. 5. Review of economy, efficiency and effectiveness of the use of resources The objectives of maximising efficiency, effectiveness and economy within the Trust are achieved by internally employing a range of accountability and control mechanisms whilst also obtaining independent external assurances. One of the principal aims of the whole system of internal control and governance is to ensure that the Trust optimises the use of all resources. In this respect the main operational elements of the system are the BAF and the Non Executive Director Committees of the IAGC and the Finance and Investment Committee (FIC). In addition there is a comprehensive system of budgetary control and reporting, and the assurance work of both the Internal and External Audit functions. The IAGC is chaired by a Non Executive Director and the Committee reports directly to the Board. Three other Non Executive Directors sit on this Committee. Both Internal and External Auditors attend each Committee meeting and report

upon the achievement of approved annual audit plans that specifically include economy, efficiency and effectiveness reviews. This year the IAGC requested reports from Executive Directors in operational areas including: • • • •

Safeguarding Children Safeguarding Adults Health Records Mandatory Training

There was also a deep dive on Patient Flows and Patient Safety. Of the internal audits monitored by the IAGC, all received at least a significant assurance opinion from the audit assessment. A Non Executive Director chairs the FIC which reports to the Board upon resource utilisation, financial performance and service development initiatives. As part of this assurance process the Divisions within the Trust presented their projected income and expenditure plans for FY14/15 to the FIC in December 2013. The Board of Directors also receives both performance and financial reports at each meeting, along with reports from its Committees to which it has delegated powers and responsibilities. 6. Annual Quality Report The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended) to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports which incorporates the above legal requirements in the NHS Foundation Trust Annual Reporting Manual. The priorities identified for 2013/14 were based on the overarching patient safety programme, which 169

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continues to be integrated with the three core areas of patient safety, clinical effectiveness and patient experience in order to provide a balanced approach to the delivery of improvements against each area. An important area in this respect was the development of a Quality Innovation and Improvement Hub (a virtual academy) where training supports the delivery of quality through service improvement. It is being rolled out with some of its components still in development. The Leadership programmes have been over-subscribed with the focus on developing a critical mass of people with the skills to strengthen evidence based practice and develop person-centred care through work based culture improvements within their teams. Responsibility for the programme is shared at Executive level between the Medical Director and the CN/DQO. The content of the Foundation Trust Quality Account was also subject to scrutiny by the External Auditor, commissioners and the Local Involvement Network (LINk). The Foundation Trust has a comprehensive programme of clinical audit in order to improve the quality of patient safety, effectiveness and experience. This year as part of the Enhancing Quality Programme these have included benchmarked monthly audits on community acquired pneumonia, hip and knee replacement, acute myocardial infarction, dementia, acute kidney injury and heart failure. In addition the Foundation Trust has been engaged in a number of audits that are part of the DoH Quality Account national clinical audit list. The patient safety and clinical effectiveness programmes are led by senior clinicians supported by managers. Reports from the Patient Safety Board (PSB) and the Clinical Audit and Effectiveness Committee (CAEC), based on a plan of work endorsed by the Board, are reviewed by the Clinical Management Board (CMB) with the minutes received by the IAGC. There are two Committees 170

supporting the patient experience programme; one is led by the Governors. Again, reports from the management group are received by the CMB and scrutinised by the IAGC. Quality interactions with patients are delivered through the use of best practice clinical and risk management policies. This year, amongst others, the CMB approved the Nutrition Policy for Adult Patients, the Nutrition Policy for Neonate & Paediatric Patients, the Policy for imaging of the Cervical Spine in Trauma Patients, the Patient Identification Policy, the Pressure Ulcer Policy and the Safeguarding Vulnerable Adults Policy. In addition the RMGG approved the Policy for Implementation of Recommendation Raised from National Confidential Enquiries and Other High Level Enquiries, the Emergency Planning and Business Continuity Policy, the Anti-Fraud Bribery and Corruption Policy, the Complaints Policy and the Health and Safety Policy. The “We Care” Steering group continue to develop the cultural change programme designed to inspire and support our teams to deliver consistently high quality experience – for patients and staff. This year the We Care values were formally adopted as the Trust’s values and work was undertaken to rebrand employee communications and management processes to align them to the values. In addition the Trust is linking this work, and the response to the National Staff Survey results into the action plan developed as a result of the Francis Report recommendations. As part of these actions, Chief Executive and CN/ DQO led discussions and road shows with staff, on the issues raised. A system of “Ward to Board” balanced scorecard reporting is well established using data derived from trust-wide systems, for example, Synbiotixs, a web-based system which records falls, infection control and other key clinical metrics as part of the monthly Clinical Quality

and Patient Safety Board Report. CQUIN and other quality indicators, developed in conjunction with the lead commissioning CCG, are also incorporated and aligned with the overall strategy. Monitoring reports for this programme are presented to the Board as the first agenda item at every meeting. The results of findings from the use of the UK Trigger Tool to record harm events to patients are used to inform these indicators and the set improvement targets. To support the quality agenda the Foundation Trust has also continued to implement the Leading Improvements in Patient Safety programme and continues to undertake training and organisational development work in customer care, team building and the use of competency frameworks supported by, amongst others, Aston University and Canterbury Christ Church Universities. The Quality Strategy underpins all that we do quality wise and aligns to our annual objectives. The data used to support the Quality Report is also reviewed as part of the monthly Balanced Scorecard report. Additional controls are incorporated within the BAF, as one of the annual objectives. Gaps in assurance are also reported as part of this process. 7. Review of effectiveness As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, clinical audit and the executive managers and clinical leads within East Kent Hospitals University NHS Foundation Trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the quality report attached to this Annual report and other performance information available to me. My review is also informed by comments

made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Board, the IAGC and the RMGG and a plan to address weaknesses and ensure continuous improvement of the system is in place. The BAF and Corporate Risk Register provide me with evidence that the effectiveness of controls that manage the risks to the organisation achieving its principle objectives have been reviewed. The Board received monthly reports on patient safety and experience and the corporate risk register for 2013/14. The Board has played a key role in reviewing risks to the delivery of the Trust’s performance objectives through monthly monitoring, and discussion of the performance highlighted in the balanced scorecard and more generally through review and discussion of the BAF. The balanced scorecard includes metrics covering key relevant national priority indicators and a selection of other metrics covering safety, clinical effectiveness, patient experience and valuing staff. The Board also receives individual reports on areas of concern in regards to internal control to ensure it provides appropriate leadership and direction on emerging risk issues. As part of this process, this year there has been one Executive Director sponsored ad-hoc piece of additional work for internal audit, this was in relation the Financial Governance review, the results of this will be presented to the June 2014 IAGC. The IAGC reviewed work in the following areas during the year: • Review and scrutiny of the Corporate Risk Register and the Board Assurance Framework • NHS LA Standards • Approval of auditor’s plans, reports and scrutiny of the

• • • •

Trust’s response to agreed actions; Governance around Information Management Review and scrutiny of the Risk Management Strategy Counter fraud, Losses and Special Payments Clinical Audit and Effectiveness

The Trust works in collaboration with Baker Tilly (formerly RSM Tenon) which provides the Internal Audit function for the Trust. Internal Audit regularly attend the Corporate Performance Management Team meetings to review all audit reports and progress against recommendations made, with particular emphasis on any reports of limited assurance. The Head of Internal Audit has provided an opinion on the effectiveness of the system of internal control. This drew on an assessment of the design and operation of the underpinning Assurance Framework and supporting processes; and an assessment of the range of individual opinions arising from risk-based audit assignments contained within internal audit plans that have been reported throughout the period. The Head of Internal Audit provided me with an opinion of significant assurance that there is a generally sound system of internal control designed to meet the organisations objectives and that controls are generally being applied consistently. Progress against the Board Assurance Framework and the resultant controls was also reviewed as part of the internal audit programme. He additionally provided me with an opinion of significant assurance in support of this Annual Governance Statement. This assessment takes into account the relative materiality of risk areas and management’s progress in respect of addressing control weaknesses. Executive directors within the organisation who have responsibility for the development and maintenance of the system of

internal control within their functional areas provide me with assurance. Review of the BAF provides me with the evidence of effectiveness of controls and management of the risks associated with achieving annual objectives. The RMGG is the principle Committee for reviewing risk in the Trust; the Committee is chaired by the CN/DQO. The Committee is supported by a dedicated and fully staffed central Risk Management Team with individuals allocated to each division. This team provided information to every Board meeting on numbers of clinical incidents by site, broken down by severity and theme, and benchmarked against previous months’ performance. The details of all reported serious incidents and progress with actions were also reported to the Board every month as was the detail around the CQC Quality and Risk Profile. Clinical Audit also plays a significant role in maintaining and reviewing the effectiveness of the system of internal control. This year the Clinical Audit team have continued with their extensive programme which aims to ensure patients have access to the same high quality standards of care no matter where they live. As a result high volume clinical pathways have been monitored around Venous Thrombotic Embolism and dementia. This year the Enhanced Recovery Programme has been supported by monthly audits in orthopaedic, gynaecology and colorectal surgery and the Enhancing Quality Programme has similarly audited the heart failure, community acquired pneumonia and acute kidney injury clinical pathways. Additionally, vital work began during the year on developing the audit methodology for the COPD and fractured neck of femur clinical pathways for live assessment as part of the Enhancing Quality Programme for 2014/15. In addition, a series of audits supported the Foundation Trust’s compliance with NHSLA 3 standards. My review is also informed by the 171

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assurance provided by external review bodies on the effectiveness of systems of internal control. In the past year such assurance has been provided by the CQC through routine and specific unannounced visits. The Health and Safety Executive (HSE) made eight visits during the reporting period; some were routine inspections and others related to complaints. Remedial actions were required and ‘Fees for Intervention‘ were received, however, no Improvement Notices were served. The actions required from three visits are still being worked through, including an extensive program around electrical work. Improved internal governance on health and safety is believed to have enhanced HSE’s confidence in the Trusts ability to properly respond to concerns and we have been asked to lead a Kent wide H&S Committee, of peer organisations, by the HSE to improve and promote learning and good practice across the county. The Trust will continue with the programme of embedding risk management and governance throughout the organisation with a view to ensuring the necessary assurances are provided to underpin the Annual Governance Statement for 2013/14 In addition, the Trust is committed to a programme of continual improvement around the controls and assurances already in place. The actions for 2014/15 include: • Improve the delivery of emergency care and implement a clinical strategy. • Further reduce the Hospital Standardised Mortality Rate. • Maintain and improve assurance of compliance with the quality and safety standards for CQC Registration across all services and sites. • Reduce the incidents of pressure ulcers, falls and catheter acquired infections. 172

• Sustain performance on achieving the overall cost improvement programme whilst continuing to upgrade the Trust infrastructure. • Continue with the work to deliver the Francis Report recommendations, “We Care” values and improve staff engagement • Continue with the successful high focus on Infection Prevention and Control. • Reduce Length of Stay and readmission rates for people with Long Term Conditions. 8. Conclusion Based on available Department of Health and Monitor guidance, the Trust’s internal and external auditors’ views and from a review of the Board Assurance Framework, the Board of Directors has confirmed that there are no significant gaps in control. Signed

22 May 2014 Stuart Bain, Chief Executive

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MONITOR’S NHS FOUNDATION TRUST CODE OF GOVERNANCE – REVIEW OF COMPLIANCE – 2013/14 Our Regulator, Monitor, has a key objective to ensure all NHS Foundation Trusts are well led. Their publication, NHS Foundation Trust Code of Governance, provides guidance to help Trusts deliver effective corporate governance, contribute to better organisational performance and ultimately discharge their duties in the best interests of patients. Monitor asks Trusts to undertake a review against the Code’s provisions and to report any areas where the Trust differs. For the provisions listed below, Monitor has asked that a supporting explanation be given against each, even in the case where the Trust is compliant with the provision. Where the information is already contained within the Annual Report, a reference to its location has been provided. Provision Reference

Relating To

Code of Governance Requirement

EKHUFT Position

A.1.1. Disclose

Board of Directors Council of Governors

The schedule of matters reserved for the Board of Directors should include a clear statement detailing the roles and responsibilities of the council of governors. This statement should also describe how any disagreements between the council of governors and the Board of Directors will be resolved. The annual report should include this schedule of matters or a summary statement of how the Board of Directors and the council of governors operate, including a summary of the types of decisions to be taken by each of the boards and which are delegated to the executive management of the Board of Directors. These arrangements should be kept under review at least annually.

The Trust’s Standing Financial Instructions includes a section ‘matters reserved for the Board of Directors’ and details the roles and responsibilities of the Council of Governors. A process for resolving disputes between the Council of Governors and Board of Directors is in place and this process has been approved by both bodies. A statement of how the Board of Directors operate can be found on page 145. A statement of how the Council of Governors operate can be found on page 156.

A.1.2. Disclose

Board of Directors Nominations Committee(s) Integrated Audit and Governance Committee Remuneration Committee

The annual report should identify the chairperson, the deputy chairperson (where there is one), the chief executive, the senior independent director (see A.4.1) and the chairperson and members of the nominations, audit and remuneration Committees. It should also set out the number of meetings of the board and those Committees and individual attendance by directors.

Details of all members of the Board of Directors can be found on page 138, together with a record of attendance. Members of the Nominations, Audit and Remuneration Committees can be found on page 146, together with a record of attendance.

A.5.3 Disclose

Council of Governors

The annual report should identify the members of the council of governors, including a description of the constituency or organisation that they represent, whether they were elected or appointed, and the duration of their appointments. The annual report should also identify the nominated lead governor.

Members of the Council of Governors can be found on page 158. Details of the Nominated Lead Governor can be found on page 159.

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Provision reference

Relating to

Code of Governance Requirement

EKHUFT Position

n/a Disclose

Council of Governors

The annual report should include a statement about the number of meetings of the council of governors and individual attendance by governors and directors.

Attendance records by governors and directors can be found on pages 158 and 157.

B.1.1 Disclose

Board of Directors

The Board of Directors should identify in the annual report each Non Executive director it considers to be independent, with reasons where necessary.

Details of all members of the Board of Directors can be found on page 145.

B.1.4 Disclose

Board of Directors

The Board of Directors should include in its annual report a description of each directorâ&#x20AC;&#x2122;s skills, expertise and experience. Alongside this, in the annual report, the board should make a clear statement about its own balance, completeness and appropriateness to the requirements of the NHS foundation trust.

Biographies for each Board member can be found on page 139, together with a statement regarding its own balance, completeness and appropriateness to the requirements of the NHS foundation trust.

n/a Disclose

Board of Directors

The annual report should include a brief description of the length of appointments of the Non Executive directors, and how they may be terminated.

Details of all members of the Board of Directors can be found on page 138. The process for terminating Non Executive director appointments can be found on page 145.

B.2.10 Disclose

Nominations Committee(s)

A separate section of the annual report should describe the work of the nominations Committee(s), including the process it has used in relation to board appointments.

A description of the work of the Nominations Committee for the Board of Directors can be found on page 151. A description of the work of the Nominations and Remuneration Committee of the Council of Governors can be found on page 160.

n/a Disclose

Nominations Committee(s)

The disclosure in the annual report on the work of the nominations Committee should include an explanation if neither an external search consultancy nor open advertising has been used in the appointment of a chair or Non Executive director.

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5 B.3.1 Disclose

how the Trust is run Chairman Council of Governors

A chairperson’s other significant commitments should be disclosed to the council of governors before appointment and included in the annual report. Changes to such commitments should be reported to the council of governors as they arise, and included in the next annual report.

The Chairman’s biography can be found on page 139 which includes a statement regarding significant commitments. Significant commitments of the Chairman are disclosed within the Directors Register of Interests and published on the Trust website.

B.5.6 Disclose

Council of Governors

Governors should canvass the opinion of the trust’s members and the public, and for appointed governors the body they represent, on the NHS foundation trust’s forward plan, including its objectives, priorities and strategy, and their views should be communicated to the Board of Directors. The annual report should contain a statement as to how this requirement has been undertaken and satisfied.

A description of processes put in place for the Board of Directors to consider the views of the Council of Governors can be found on page 156.

n/a Disclose

Council of Governors

If, during the financial year, the Governors have exercised their power* under paragraph 10C** of schedule 7 of the NHS Act 2006, then information on this must be included in the annual report. This is required by paragraph 26(2) (aa) of schedule 7 to the NHS Act 2006, as amended by section 151 (8) of the Health and Social Care Act 2012. * Power to require one or more of the directors to attend a governors’ meeting for the purpose of obtaining information about the foundation trust’s performance of its functions or the directors’ performance of their duties (and deciding whether to propose a vote on the foundation trust’s or directors’ performance). ** As inserted by section 151 (6) of the Health and Social Care Act 2012)

A description of the processes in place can be found on page 157.

B.6.1 Disclose

Board of Directors

The Board of Directors should state in the annual report how performance evaluation of the board, its Committees, and its directors, including the chairperson, has been conducted.

A statement on Board, its Committee and individual director evaluation is included on page 146.

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B.6.2 Disclose

Board of Directors

Where there has been external Not applicable for 2013/14 evaluation of the board, the external facilitator should be identified in the annual report and a statement made as to whether they have any other connection to the trust.

C.1.1 Disclose

Board of Directors

The directors should explain in the annual report their responsibility for preparing the annual report and accounts, and state that they consider the annual report and accounts, taken as a whole, are fair, balanced and understandable and provide the information necessary for patients, regulators and other stakeholders to assess the NHS foundation trustâ&#x20AC;&#x2122;s performance, business model and strategy. There should be a statement by the external auditor about their reporting responsibilities. Directors should also explain their approach to quality governance in the Annual Governance Statement (within the annual report).

A statement regarding Director responsibility for preparing the annual report and accounts can be found on page 40.

C.2.1 Disclose

Board of Directors

The annual report should contain a statement that the board has conducted a review of the effectiveness of its system of internal controls.

A statement can be found as part of the Annual Governance Statement on page 166.

C.2.2 Disclose

Integrated Audit and Governance Committee / Control Environment

A trust should disclose in the annual report: (a) if it has an internal audit function, how the function is structured and what role it performs; or (b) if it does not have an internal audit function, that fact and the processes it employs for evaluating and continually improving the effectiveness of its risk management and internal control processes.

A statement can be found as part of the Annual Governance Statement on page 166.

C.3.5 Disclose

Integrated Audit and Governance Committee / Council of Governors

If the council of governors does not Not applicable for 2013/14. accept the audit Committeeâ&#x20AC;&#x2122;s Recommendation on the appointment, reappointment or removal of an external auditor, the Board of Directors should include in the annual report a statement from the audit Committee explaining the recommendation and should set out reasons why the council of governors has taken a different position.

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C.3.9 Disclose

Integrated Audit and Governance Committee

A separate section of the annual report should describe the work of the Committee in discharging its responsibilities. The report should include: • The significant issues that the Committee considered in relation to financial statements, operations and compliance, and how these issues were addressed; • an explanation of how it has assessed the effectiveness of the external audit process and the approach taken to the appointment or re-appointment of the external auditor, the value of external audit services and information on the length of tenure of the current audit firm and when a tender was last conducted; and • if the external auditor provides non-audit services, the value of the non-audit services provided and an explanation of how auditor objectivity and independence are safeguarded.

The Annual Report contains a statement on the work of the Integrated Audit and Governance Committee and this can be found on page 148.

D.1.3 Disclose

Board of Directors Remuneration Committee

Where an NHS foundation trust releases an executive director, for example to serve as a Non Executive director elsewhere, the remuneration disclosures of the annual report should include a statement of whether or not the director will retain such earnings.

Not applicable for 2013/14.

E.1.5 Disclose

Board of Directors

The Board of Directors should state in the annual report the steps they have taken to ensure that the members of the board, and in particular the Non Executive directors, develop an understanding of the views of governors and members about the NHS foundation trust, for example through attendance at meetings of the council of governors, direct face-to-face contact, surveys of members’ opinions and consultations.

A description of processes put in place for the Board of Directors to consider the views of the Council of Governors can be found on page 156.

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E.1.6 Disclose

The Board of Directors should The Membership Report can monitor how representative the be found on page 164. NHS foundation trust’s membership is and the level and effectiveness of member engagement and report on this in the annual report.

E.1.4 Disclose

Membership

Contact procedures for members who wish to communicate with governors and/or directors should be made clearly available on the NHS foundation trust’s website and in the annual report.

The Membership Report can be found on page 164.

n/a Disclose

Membership

The annual report should include: The Membership Report can • a brief description of the eligibility be found on page 164. requirements for joining different membership constituencies, including the boundaries for public membership; • information on the number of members and the number of members in each constituency; and • a summary of the membership strategy, an assessment of the membership and a description of any steps taken during the year to ensure a representative membership [see also E.1.6 above], including progress towards any recruitment targets for members.

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Provision Reference

Relating To

Code of Governance Requirement

EKHUFT Position

B.2.3

Nominations Committee(s)

There may be one or two nominations Committees. If there are two Committees, one will be responsible for considering nominations for executive directors and the other for Non Executive directors (including the chairperson). The nominations Committee(s) should regularly review the structure, size and composition of the Board of Directors and make recommendations for changes where appropriate. In particular, the nominations Committee(s) should evaluate, at least annually, the balance of skills, knowledge and experience on the Board of Directors and, in the light of this evaluation, prepare a description of the role and capabilities required for appointment of both executive and Non Executive directors, including the chair person.

Although the requirement to evaluate the balance of skills, knowledge and experience on the Board of Directors is not a new requirement, from 1 January 2014 there is a requirement to undertake this evaluation at least annually. The following describes the current processes in place and our plans for introducing an annual evaluation from 2013/14. Nominations and Remuneration Committee of the Council of Governors Nominations and Remuneration Committee of the Council of Governors review the size, structure and composition of Non Executive Directors and Chair each time there is a NED term of office expiry. Terms of Reference for this Committee have been amended to formalise this review to be undertaken on an annual basis from 1 April 2014. Nominations Committee of the Board of Directors Nominations and Remuneration Committee of the Board of Directors review the size, structure and composition of the Board when there is a vacancy. In addition, the Board of Directors considers this requirement as part of its annual performance evaluation. Terms of Reference for this Committee have been amended to formalise this review to be undertaken on an annual basis.

B.2.4

Nominations Committee(s)

The chairperson or an independent The Nominations and Remuneration Non Executive director should chair Committee responsible for the the nominations Committee(s). recruitment of Non Executive Directors is chaired by a Governor. The Chairman attends Committee meetings in an advisory capacity relating to Non Executive Director appointments. The Senior Independent Director is invited to attend the Committee in an advisory capacity relating to the appointment of the Chairman. The Nominations Committee responsible for Executive Director appointments is chaired by a Non Executive Director.

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D.2.3

Council of Governors Remuneration Committee

The council of governors should consult external professional advisers to market-test the remuneration levels of the chairperson and other Non Executives at least once every three years and when they intend to make a material change to the remuneration of a Non Executive.

The Nominations and Remuneration Committee of the Council of Governors undertakes this role. The Committee undertakes an annual review using benchmarking information obtained from the Foundation Trust Network. External professional advisers have not been consulted in the last three years.

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